Lt Tata Indicom Broadband indicom [EROADBAND} Perel Rely Ula Ue asl Name of the Customer: CLEETT TTT TTT TTT TTT TTT TTT TT TTT TTT) User Name: Contact person: Existing Address: city: state Ll STD code: Tek Mobite: Landmark Slama Required Address: ity: PIN: State: Fax STD code: Tel: Mobile: Landmark Charges: (Rs.) Date when connection is to be shifted ao we ey esa eae) Required Address: For shifting of location all outstanding dues are required to be paid City: CLETTTETT TTT TTT TTT State: Fax ] I STD code: CLIT) CLEETTETTTT Landmark: CLUTTTT TTT TTT Tt ttt tt Charges: (Rs. CTT) PEE Plan change: Existing Requirea__________ charges Rs.) T | | 11] CPE Change: Existing _________ Requirea________ charges Rs) —T TT [1] re IDs" Existing Required Charges (Rs.) Existing Required ___________ charges (Rs.) Existing Required charges Rs.) [] | ] 11] Total Charges payable: (Rs.) Remarks: Note: Charges as applicable need to be entered by te VSNL representative. Ifno charges applicable, then NIL to be mentioned Discover the infinite possibilities of Broadband * LEARNING + EDUCATION - BUSINESS + COMMUNICATION PLN indicom Re ec TL SAD SANDhis Tata Indicom Broadband indicom Perel Rely Ula Ue asl EXO Payment Mode: Cheque Doman Draft “Amount (Rs. Cocco ‘Cheque /DD issued on Bank: Branch: CLEVE TTT TTT TTT TT TTT TTT TTT TT Tt ttt) ‘cheque /DD No: Dated: DECLARATION IN CASE PAYMENT IS MADE BY AN INDIVIDUAL / ORGANISATION OTHER THAN THE APPLICANT ‘This is to confi that | am / We are making the payment to VSNL on behalf of Name of the individual / Organisation making payment: ‘Signature / Stamp: PE a eee We state that | am /We are the applicant forthe aforementioned service and that | We shall indemnify and keep indemnified VSNL, in case the above Information given is found to be false and / or in the event of any claim including third party claims arising as a result of this Plan change / Shift/ Additional services request. |. We have carefully read the Tata Indicom Broadband Terms & Conditions and technical specifications and agree to abide by the same 1am / We are aware that the Terms and Conditions as may be modified from time to time, as applicable tothe service are avaliable at wu tataindicombroadband in and the services shall be used in accordance with the same, Signature of Customer: ‘Company Se: (Wherever applicable) cae eg DSA Name: City ‘Channel DSA. DSA Code: DSA Executive Name: City ‘Channel DSA | Executive DSA Executive Code: e Signature ‘Stamp of DSA 7 Eicon l Date. | /we acknowledge receiving from MrJMs. ‘a payment of Rs. towards by way of Cheque / DD. (Cheque / DD No. Cheque / OD Date Executive Name Executive Tel No. SealiSign ‘Tate Indicom Customer Service No, errr]