Form 'A

  I/We wish to subscribe for Internet services, necessary particulars as given below:

 

1.    Name

 

2.   Address

City

State

PIN Code

                                                                                                                    Prefix STD Code without 0

3.  Telephone Nos. from where internet is to be         (1)
Accessed                                                         (2)
4.  Contact telephone No.                                       (1)
(2)
5.  Fax no.

                                                                                         

6.   Contact E-mail id (if any)

 

     7.   Existing Service details (to be filled in case of renewal only): 

 

P.S.T.N. Dial up	25hrs	50hrs	100hrs		200hrs		500hrs			1000hrs
or
ISDN Dial Up				100hrs		500hrs			1000hrs
Speed of Access for ISDN				64 kbps				128 kbps

                                                (five to ten characters)

Dialup User ID
Email ID            (1)											@sancharnet.in
(2)											@sancharnet.in

        

     8.  Service Details (for new account): 

 

P.S.T.N. Dial up	25hrs	50hrs	100hrs		200hrs		500hrs		1000hrs
ISDN Dial Up				100hrs		500hrs				1000hrs
Speed of Access for ISDN				64 kbps				128 kbps

                                                      (five to ten characters)

Dialup User ID

 

Alternate Dialup User ID   (1)
(2)
(3)
(4)

 

9.   Payment Details	Cash/DD No.	Bank Name	Branch	Date	Amount

 

I have gone through the Broad Terms and Conditions of the services at Annexure I  and agree to abide        by the same.

                                                                                               

                                                                                                              Signature

Date:                                                                                                       Applicant's Name

 

 

 

 

 

---

 

OPTIONAL INFORMATION, IF FILLED WILL HELP US IN IMPROVING OUR SERVICE

 

2.       Have you got any other Internet account. If yes, kindly indicate:

 

Type of Account:
 

      Name of ISP:

 

3.       What additional facilities you expect, please mention:
 

4.       For what purpose you intend to use/using Internet:

 

5.       What is the average number of hours per week, that you surf  Internet:

 

6.       Suggestions if any:

 

 

TARIFF  : For the latest tariff please see internet section of our website www.bsnl.co.in

 

 

PASSWORD ACKNOWLEDGEMENT RECEIPT FROM THE CUSTOMER

 

I have received the envelope bearing the customer code _________________containing the password for applied Sancharnet (NIB) Internet Services.

 

 

Date                                                                                                         Signature of Customer

 

 

For Use of NIB Node-in-charge