ffi BHARAT SANCHAR NIGAM LIMITED1zOg1

(A Government of lndia Enterprise)

tsSNL [Customer Agreement Form for New Landline Telephone Connection] Affi x Crossedself Signed
Can**l*^<li* Photograph

(PLEASE USE CAPITAL LETTERS FOR FILLING UP THIS FORM)

--9
1 Companyiorganisation Nationality

3 Name of Customer/Company/Firnl/Organisation
4 Father/Husband,lcroup/eroprletorlParte(s)

5 Gendei Male f Female E Transgengs n 6 Date of Bidh (owdlu/yyyy)

7 PAN/GIR No. Or lT Declaration in Form 60/61, as applicable I Nos of Telephones required

8 Contact oetails: E-Maalld

9 A Prof of ldentity encloscd

(PI see instruction no.4)
B Proff of Address enclosed
(Pl see rnstructron no.4)

10 Category Code: (Pl see Category an lnstrcut,on no 2) 11 Coceslonal code, if applicable (sc instruction no. 3 for codc)

12 eurpose Residence tr Business tr covt. l-l others I psu X

13 Facilties Required isDNlBroadband n (fYes, then a sepaEte Form may be tilled)

STD i$ by Default tsD I er-r I Honine []] confrencing tr calt Foilarding L]

'14 lnstallation aodrels (where telephone is to be instailed) (Enclose Proof ot address)
House No. StreeURoad,A/illage ArealLocality/Tehsil

Brd9./APPl. City/Dlstrict State FiN

'i5 Billingicoresponoenc Mdress, it diffrent irom installati*iJ address

Hese t o. StreevRoa(l/village Area/Locality/Tehsil

Bldg.rAppL City/District State PIN

Telcphone lnstruments 17 lnternal wiring TariffPtanopted

16 |],t,.eetaritrptansavaitabte)
19 Name of Nominee, if any

2A lniEal Fayment details: Amsuni Rs Cash | | For Cheque/DD/CrediuDobit Card

(Towants scudty deposit, Rs 5oU- where waitlnglisiTEiliEi{ NIL whei6on Demand Telephne available}

and acccptance by BSNL ! am nd a detaulter s account of non payrenl of bills for any telecom sepice prcvidr & I am abide by the prevaaling lndian TelegraPh Ac-t Rules.

Signature of GustomerlAuthorised Signatory Signed at Place Signed on Date Seal of Companl'llnstitution(if applicablei
TNSTRUCTIONS FOR FTLLTNG THE FOBM FOR LAND LINE CqNNECTtoN

be atached. tn se ot Govemmenl Depadnents, authorised pe6on may sign and aftix rubbe. stamp
2. 93@99g9: 1. N-oYT-eeneral2. N-oYT-Spl 3. N-O.YT-SS 4. N-oYTWS 5. N.OYT-G.SE/DOT

institutions/qganizaliqs recogilized by Govemmant, 7: Retired DOT, 8.Relired-BsNL,9.Serying-DoT,10. Serying-BSNL.

4.Dogu6enBEogiEdt9besUbmtttedas,roofofldentjtv,Addressi@(allidentilyprooftohavephotoofapplicant)'thecudoffislEl|sbmilanyoneofthefdlwing:

Fredom Fightercard having photo and Kissan pas,s b@k having photo.

ordinating ofiicerto be consulted in case of need

address-
919!g!EIeg.q!49 are required to enclose the copy of Passport.

For Office Use OnlY

Certify that the identity, bonafide anc adoress ui iire appiisant has been verifided by n'ei my reprasentative-
l.lameofdealerlpon;to'",,u.,'-ffiad'icel'.totelyvorkorde!,: -
Checked requisite documents are enclosed STE Code lncjicatcr nvm[g DD iUtuL .yYYr ---
-
DateofreceiotofFormrmTelephonel,.lt.:lero,o,,.*,Till-_ -

Sgna]ure oI otr-r.ialwitFDeaignation & oftice stamp --. -Si-g-n.ilure of0trIdlalwith designation & otticaal seai

-
 )i

ffi
BSNL
A"$*tlr/:*
Applicatior'! Forrfi fCIr Broadband Service $mta@we BroadbancE
Flease filtthe application foi"m in capital letters oniy.

1. Existing BSNI- Telephone No. on which Broad Band Connection is required.

2. Wantto aPPIY for a new connection V"rI Non

3. EducationalGualificatien{Optional) Doctorate/Post-
Gradr.rate/Graduate/M atricu lation/Others
(Kindly enclose the copy of the latest Telephone b!ll)

Tifl e/Nanne of the eustomerlcompanylorganization (${-} RNAME r! R$T)

,
!

5. EiNiing Address

a :

Addresi: *t- C0n n**, t*'n

t. Mobile

8. Type of Broadband use : Business / Residential

9. Modem Options Rental I Purchase

10. Choice of Tariff Plan ($ee enclosed annexurei (e.9. Home 1800)

Payrnent OPtions : nnnuatty f

I

MonthlY

11. Ghoissof e-mail*.rserlD: (i).....' (ii) .". " "'

(iii)............,. (ivi ' ... .

(lncase preferred user name is not available BSNL iarili Flrovide one user ilame #ellerated by the systern)

12. Nomifiee (OPtional)

i
lil
13. Customels Signature
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 http : //www. bsnl. in/opencms/bsnl/B SNUservice s/broadband/broadban...

t.:4....:

*t1 h?,i,'Y &N{Y, &X W& L1}.tlTYb llome l-aq Aboui k4\
{*J*L & &tu4 lJs

Broadband Unlimited Plans

s
_Ii
1
Upto + ,Opt trlr 10 GB, Upto 4 Mbps tril 20 GB,
Upto 1 Mbps beyond : Upto 1 Mbps beyond
2 at those places in all the circles where BSNL is not able to provide voice facility
3
i lu %, I rrse t 144,
4 Annual Payment Option (Rs) [11 x FMC]

Payment Option (Rs) 130 x

6

Download/Upload Limit ([4B/GB) per

7 Unlimited

o Addilional Usage Charges/l'48 beyond free

" download/ upload lrm,t (Rs,)

Free E-mail IDs/Space (Per E-mail ID) 1/1 GB

Static IP Address (On Request) , NA

One Month Charges

Telephone fixed monthly charges in Rs

Free calls (within BSNL N/W only)

Voice facility is not available. No telephone instrument is to be provided.There are no charges

towards landline Registration/Landline installation/Landline Security deposit.
[ 1r" asruL ruu w
after free calls)
(To other N/W )

About Us Services Directory Services My Account Contact Us

. Company . Landline . India Telephone Drectory . Pay Landline/Broadband B ll . Reach Us
. HRD .l'lobile . Toll Free Number . Pay f,lobie Bill . Srtemap
. F nance . Broadband . Pay WLUCDMA/EVDO BilL . Feedback
. RTI . Enterp.ise Services . l.lolbie/CDt\,1A Duplcate Bi . FAe
. Consumer Grrvances . Help Desk . SMS Alerts
. Downloads

I of 1
5111117,4:02 PM
 http ://www.bsnl. irvopencms/bsnl/BSNuservices/broadband/BBj1ans...

Broadband Unlimited Plans

Partlcu lars
BBG
BBG BBG BBG ULD
Combo BBG Combo
Combo 1491 EA
UL ULD 680 ULD 1199
1445#
675** ASOM###
Upto 4 Upto 4 upto 4 Upta 4
Upto 4 14bps l,lbps Upto 4 Upto 4 Mbps Upto 4 Mbps till
Mbps Upto 4lvlbps tlbps till till
tiil 5 till 5 GB, till 10 tiil 10 Mbps till 10 tiil
20GB, l'4bps 60
70 GB,
10 GB, GB, Upto 1 upto 2MbPs GB, Uptol
GB, 1
Upto 1
GB, upto 1
Upto 1 Mbps beyond Mbps
upto 1
Mbps
1

Mbps Mbps beyond beyond

beyond

All Users
-t:
sso I rrss''::_
| ;;;
lYonthly Charges 499 7ss : 845 ] o+s I

a;
(Rs)
-
Payment
(Rs) [11 x 74Bo B74s 929s ro:ss | 10450 13189
5489
I
:iLj
Two Years 19950 25779
1417s 1 6695
Payment OPtion
(Rs) [21 x FMC] I
!

16350 ,ZOZSO I 20400 :23850 zs:so ze:so 43350

(Rs) [30 x FMC]

Download/Upload
Limit (MB/ GB)
per month

1/1 GB 211 GB i 1/1 GB

1/1 GB

Static IP Address NA
t'NA - One @ Rs
2000/- p.a,
One @ Rs
2000/
,run LNA
(On written
Request)
NA
-[-: ll add itional a dd ition

Two Month
a I

Security Deposit charges

One Month charges
One Month
Month

Telephone fixed
I -;.' I ;;.
monthly charges
in Rs
NlL
ll
Free Calls(with in ^,,,
rrrr
BSNL n/w)t As per

F
Existi ng
MCU Charges/ Landline
pulse in Rs. (to Plan
BSNL n/w after
Free Calls) As per
24 hrs. Existing

F;
Unlimited
MCU Charges/ I
free calling r.20 Landline
pulse in Rs, (to 1.20
( Local+STD)
Plan
Other Network) on any
network
free calls within lndia
between 9 As per unlimited free calls Pl'4to 7 AM
PMtoTAM Existing Unlimited free calls between 9
between 9 PM to 7 AM PMto 7 AM & on all Sundays to & on all
& on all Land line & on all Sundays to any network in India Sundays to
Sundays to Pla n
any network in India any
any network in
network in India

### ASOM : Additional Storaoe on Messagino Service

* ln lrce calls rncler combo plens are offered as 50r)'Lr talls witlrin BSNL l'l'/w and
NCR SSAs (only in Faridabad, chaziabad, Gurgaoir & Noiiia), available
50o,/o calls to other N/w w.e.f. 01-04-2013.

Note:-
ssA's of MP Circle and
r, @ FMC under broadband
,,BB
Home UL 545" plan is Rs.645 in the odisha circle, Selected ssAs of uP(west) circle , selected
selected SSA5 of I"laharashtra circle.
,. ^ Plan is not available in l&K Circle only.
* plans is Rs.775, Rs 899, Rs'1000
BB Home Combo UL 675','BB Home Combo ULD 845",'BBG Combo ULD 945"
,,
r,. * FMC under broadband
circle, Selected of UP(West) circle , selected SSA's of UPE circle, selected SSA's of N'lP Circle and selected SSA's of
respectively in the Odisha SSAS

5111117.4:02 PI
2 of3