BHARAT SANCHAR NIGAM LIMITED
(http://www.bsnl.co.in)
FORM FOR NEW TELEPHONE CONNECTION
ffix self signed passport size photograph
(required for ISD facility only)

Companies/ Organization  
( Please tick the appropriate box)

 

Individuals

 

 

( Please read the instruction before filling the form )

 

1. A Title/Name of the Customer/Company/Firm/Organization ( SURNAME FIRST)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Name of the Joint Applicant, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Name of the Nominee                                                                                                      Relationship to the applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Name of Father/husband/Group/Proprietor/Partner(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.PAN/GIR No.

 

 

 

 

 

 

 

 

 

 

4.Tel No. working, if any

 

 

 

 

 

 

 

( please see Instruction #2)                      

4.a   Nearest Telephone No.  

 

 

 

 

 

 

 

5. Complete Postal Address

 

House No

 

 

 

 

 

 

 

Street/Road/Village

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bldg/ Appt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area/Locality/Tehsil

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/District

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PIN

 

 

 

 

 

 

 

6. Billing/ Correspondence Address ( if different from 5 above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. E- mail adress ( if any) :  _________________________@_________________________

8.Category Code(Please write code no. as indicated in instruction no.10)

 

9.Concessional Group Code. (Please write code no.as indicated in instruction no.11)

 

10.Purpose:Residence

 

Business.

 

Govt.

 

PSU

 

11. Facilities required ( tick whichever is required) ( please affix photograph for ISD facility):

            STD

 

ISD

 

CLI

 

Hotline

 

Conferencing

 

Call forwarding

 

Abbreviated Dialing

 

12.Whether Telephone instrument is required(Y/N)

 

13. Whether Internal Wiring is required  (Y/N)

 

14.Payment Mode : Cash

 

Demand Draft

 

Amount

 

 

 

 

 

 

 

 

     Payment Details: DDNo.

 

 

 

 

 

 

Dated

 

 

 

 

 

 

 

 

     Drawn on:             Bank

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                 Branch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby declare that information given above is true to the best of my knowledge and I will abide by the prevailing Telegraph Act/ Rules framed there under & Tariffs as amended from time to time. I am not a defaulter on account of on-payment of bills for any telecom services provided by any service provider.  In the event of any dispute concerning any telecom line, apparatus or appliance, bill etc., between me/us and BSNL, the matter will be referred to the sole Arbitrator, appointed by a nominated authority in BSNL and shall be governed by the provisions of the Arbitration and Conciliation Act, 1996.


Signature of  Customer/Authorised Signatory


Signature of  Customer/Authorised Signatory

Signed on :         Date