SNL. G BHARAT SANCHAR NIGAM LIMITED 3 (A Government of india Enterprise) A generation ahead (cusToMeR AGREEMENT FORM FOR PREPAID CELLULAR CONNECTION) photograph TieMName of the CustomeriCompanyiFiem/Organization (SURNAME/FIRST NAME/MIDOLE NAME) Name of Father / Husband /Group / Proprietor / Partner(s) COO O Cee EC COCC COCO 4 Customer Category individual une Public Lt. Pvt Lid owt |] others specity 5 Profession: Service Self Employed Professional Student House wite|__| others specity 6 sex: wate [[] tamate[] 7 wartasaus: singe [] Marea comers: § OOCCOOOo LOO OOO {9 PAN/GIR No.{n case PAN / GIR No. not there submit IT declaration in Form 60/61 ) 10 Working Telephones Nos, 2) BSNL b) Others, ©) Fax 11 E-mail address @ 12 Nationatiy ee ee O UOC Lo LH 430 Office / Business Addr LUDO) O DOr Phone: 14(a) Proof of photo identity (Refer Clause 23) 14(b) Proof of Address(Refor Clause 2.2) 418 Facilly Required (tick whichever is required) (* Corresponds to 3G Services only) sw 18 National Roaming Intemational Rearing [_] temised Bling Mobile TV* Video on Demand? Video Conferencing Others (tobe specified) 16 Whether the tlaphone ito be included in Nationa De Not Call NDNC) regs vee ne 17 Taipan Oped (Retor Tari plans) (@)For2G Services: Standard” [——] other (o)Fora6 Services: woice plan [J bata Plan any) S Out ston customer Phone No. any) Payment mode Cash heave Demand Dealt Cred Debit card amount Tl O Certified thatthe identity, bonafide and address of tho applicant have been verified by me my representative Tse of Deal] Pao Sale Denies Code and Sip aa FOR OFFICE USE ONLY Otome SEEDED wens SEOCOOOOo Signature of Oficial DesignationTERMS & CONDITIONS ES a rae nomena eee coven ‘Salta Sap espero rata sett ey sae [Rims Once geauaaun eateries Goethe Mocks earns