Application cum Agreement Form for allotment of PCO

Affix self signed photographList of doucments required:
1 Photo Proof of Identity Proof of residence Proof in support of priority category, if any PAN/GIR No.
Instruction for filling up of application form:
1 The form must be filled up in capital letters only. No column should e left blank. Leave one box blank between two words.
2 Please tick (√ ) the appropriate box
3
4 In case application is for more than one PCO, the amount to be enclosed with application should be calculated by multiplying the amount of
security deposit by numbers of lines. Consolidated payment can be made for all the lines.
5
Self attested copy of PAN/ GIR No. / form 60/61 (not required in case of organisation)
6
7
8 Age in completed years should be mentioned in column 5.
9 Information asked in colum 12 is as per the guidelines of the licensor.
10
11 The initial security deposit amount may also be deposited in cash at the cash collection counter of customer service centre of the area alongwith the
application.
12 For details of Security deposit and latest tariff are also available on the website www.bsnl.co.in
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14

( Please read the instructions carefully before filling the form)
PART-A
(PLEASE USE CAPITAL LETTERS FOR FILLING UP THIS FORM)
1 A. Name of the applicant
(SURNAME) (FIRST NAME) (MIDDLE NAME)
B. Sex: Male Female
2 Name of the institution / organisation (if applicable)
3 Name of Father / Husband of the applicant
(SURNAME) (FIRST NAME) (MIDDLE NAME)
4 Nationality
5 Date of Birth (dd/mm/yyyy) 6 Age ( completed years)
7 Type of applicant : Individual Organisation
8 Category of the applicant: War Widow/Depandants Handicapped SC/ST
Ex.Serviceman Charitable Institution Hospital
Defence Establishment Para-Military Establishment Others
9 Type of access Prepaid Basic (Fixed including WLL) Post paid basic (Fixed including GSM mobile (post paid)
10 Facilities required Local & STD Local, STD & ISD
11 PCO's proposed name
12 Number of PCO lines required 13(a) Do you have an existing PCO No.(s) Yes No
13(b) If yes, name of service provider 13(c) Indicator No.
14 Do you wish to act as outlet for other BSNL services.
If yes, the services you proposed to provide :
i Sale of Excel/Cell One Cards ii Sale of all types of recharge coupons
iii Broadband connections including modem iv IPTV connections including set top box
v Sancharnet cards, ITC cards and other type of cash cards vi Bill collection of all post paid services through DD/cheque
vii Information kiosks for various BSNL services & products viii Booking of telegrams and delivery thereof
ix Display/sale of various type of telephone instruments accessories. x Any other service for customer convenience
15 PAN/GIR No. 16 E-Mail address (if any):
(In case PAN/GIR No. is not provided, declaration in Form 60/61, to be furnished)
17 Proof of address: Passport Electricity bill Driving licence Ration Card Telephone bill Others
(attach copy of any one) (Please specify)
18 Proof of personal identity: Passport Voter ID Photo ID Arms licence Others
(attach copy of any one) (Please specify)
Driving licence Income TAX PAN Photo Credit Card
19 Bank details Name of the Bank
Branch
Account Number
Nature of Account Savings Current
20 Credit Card details (if any) Name of the issuing bank
Type of card Gold/Dinars Others
Card Number
Expiry Date (dd/mm/yyyy)
21 Installation address (where PCO is to be installed)
PIN
22 Residential Address
House No. Street/Road/Village Area/Locality/Tehsil
Bldg./Appt. City/District
23 Bills to be sent to : Installation address Residential address
24 Payment details: Cash Demand Draft
(Towards security deposit, if applicable)
Amount (Rs.)
Demand Draft No. Issue date (dd/mm/yyyy)
Drawn on Bank Branch
Signature of applicant
BHARAT SANCHAR NIGAM LIMITED
(A Government of India Enterprise)
(website : www.bsnl.co.in)
Office of GM TD________________________

C
Received one application for Public Telephone Form
M/s. / Mr. / Ms. (Name and address of the applicant)
Organisation/Institution :
Registration No. Exchange allotted
O B No. Date (dd/mm/yyyy)
Documents received with application form (Please tick which ever is applicable):
Agreement form duly signed on each page by the applicant.
Photo
Proof of Identity
Proof of residence
Proof of priority category, if any
Defficiencies observed (Please tick which ever is applicable)
Agreement form not signed on each page by the applicant.
Photo not submitted
Age proof not submitted
Proof of Identity not submitted
Proof of residence not submitted
Proof of priority category, if any,not submitted
Any other discrepency (Please specify) ---------------------------------------------------------------------------
Date Signature of Receipt assistant/ DSA
Original of the documents enclosed with the application should be brought at the time of submission for verifications.
CUT FROM HERE
Acknowledgement
BHARAT SANCHAR NIGAM LIMITED
One self signed photo ( in case of application in the name of organisation, photo of the authorised signatory) should be pasted at the space provided.
Demand Draft of appropriate value for Urban/ rural area should be drawn in favour of Acconts Officer BSNL---------------------of the area.
The applicant should sign on each page of the application-cum-agreement form to him/her duly signed by authorised office of BSNL after acceptance of
his application .
Male applicant and unmarried female appliant should write their father's name in column 2. Married female applicant should write their husbands name.
Applicant should write his/her surmane first in column 1. In case space provided is insufficient, abbreviation should be used for middle name. I/We declare and undertake that the above information is wholly true. I/We have read and understood the terms and conditions
mentioned in the Annexure forming integral past of this Application Form. I/We hereby agree to abide by them.
________________________________ __________________________
Dated : ___________________ Signature/Left thumb impression Seal of Company/Institution
of the applicant/authorized signatory (if applicable)
TERMS AND CONDITIONS:
These Terms and Conditions form an integral part of the accompanying PCO Application Form (“PCOAF”) and govern the provision of the Services (as
defined hereunder) by Bharat Sanchar Nigam Limited (BSNL) and/or any Designated PCO Operator, pursuant to the said PCOAF.
1. This agreement between PCO Operator and BSNL shall be on Principal to Principal
basis (P2P) and neither party can bind the other except as provided in this agreement.
2. BSNL shall not be responsible for conduct of the business of the PCO. Any risk/loss
associated with running of the PCO shall be borne by the PCO Operator only.
3. The PCO Operator will be provided connectivity with BSNL’s network through wire
line/wireless connection. The Telephone number allocated to PCO Operator shall
remain exclusive property of BSNL, PCO Operator being allowed only during the
agreement period to use it to obtain access to the network and telephone number shall
be deemed to have been returned by the PCO Operator upon the
termination/determination hereof and/ or upon disconnection or temporary suspension
of services.
4. Except where and to the extent an exception has been granted by BSNL either specific
to the operator or in general covering all or select operators, the PCO operator will
provide only the BSNL/TEC type/interface approved telephone instrument, a charge
indicator operating on 16 KHz, Printer or an attachment at his own cost. The Charge
indicator would not be programmable locally.
5. As part of price arrangements between BSNL and the PCO Operator, the PCO Operator
agrees to deposit with BSNL, as refundable security deposit, such amount(s) as may be
determined by BSNL from time to time. PCO Operator also hereby gives BSNL the
irrevocable right to increase the amount of security deposit from time to time either as a
general policy for PCOs or specific to the PCO Operator which may be decided by it
based on payment practice of the PCO Operator or other considerations and the PCO
Operator agrees to deposit the sum asked by BSNL. The PCO Operator hereby gives
BSNL the irrevocable right to forfeit/adjust or apply the said amount of security deposit,
including the additional amounts of security deposit, in full or in part satisfaction of any
sums due from the PCO Operator to BSNL at any time. The PCO Operator shall
continue to be liable to make payment for balance dues, if any still remaining unpaid, to
BSNL
6. The PCO Operator shall comply with all applicable laws, bye- laws, rules, regulations,
orders, directions, notifications etc. of the Government / Court /tribunals and shall also
comply with all directions issued by BSNL which relate to operation, of PCOs and
provide BSNL with all information and co-operation that BSNL may reasonably require
from time to time.
7. The PCO Operator will fully cooperate with BSNL to investigate any complaint from
the public.
8. BSNL will have the right to inspect the premises at any time, without notice, so as to
ensure that the PCO is working as per the prescribed conditions of the agreement as
also that the charges taken from the public are within the maximum prescribed limits.
9. The PCO Operator will not be entitled to any rebate on account of alleged wrong calls
or alleged excess metering.
10.The PCO Operator will permit his customers to make calls free of charge from his PCO
to all emergency service numbers and all the toll free numbers and shall not deny access
to such numbers in any manner, whatsoever.
11.The PCO Operator shall be free to advertise the existence of the facilities of his PCO.
12.All applicable taxes/cess/duties etc. that may be levied by the Government /local
authorities etc. will be billed to the PCO Operator’s account.
13.PCO Operator will not use, or allow the services of his PCO to be used by any person,
for any unlawful, immoral, improper or abusive purpose or for sending obscene,
indecent, threatening, harassing, unsolicited message or messages affecting/ infringing
national interest, nor create any damage or risk to BSNL or its Network and /or other
PCO Operators.
14.Except as specifically provided in this agreement, either party may end the agreement
by giving the other party not less than 15 days prior written notice to end this agreement
but such a notice shall not absolve PCO Operator of its liability to make the payments
of the amounts that may be due and outstanding as on date of notice or as may become
due subsequently.
15.During the period of 15 days notice by the PCO Operator for ending this agreement and
disconnection of PCO, the PCO shall be treated as working even if the said PCO was
not in use and the PCO Operator will be liable to pay all the charges including
minimum guaranteed revenue as applicable.
16.Notwithstanding anything contained in this agreement and without any liability to pay
or compensate for any loss of business in any way, BSNL may at its sole discretion and
unilaterally revoke or suspend this agreement with the PCO Operator and/or withdraw
the services either totally or partially at any time without giving any notice if:
(i) the PCO is found to be used in any activity in violation of any law of the country or,
for any unlawful, immoral, improper or abusive purpose or for sending obscene,
indecent, threatening, harassing, unsolicited message or messages to any person,
(ii) the PCO Operator is creating any damage or risk to BSNL or its Network and /or
other PCO Operators,
(iii) breach or violation of any of the terms & conditions of the agreement is being or
has been committed by the PCO Operator including but not limited to nonpayment of bill by due date,
(iv) a direction from Government is received in the interests of maintenance of law
and order, public safety and interest or defense of India, Civil Defence or
Internal Security
Provided the authority in BSNL shall not take any action under this clause unless
the authority has recorded in writing the reasons for doing so:
Provided further that the authority in BSNL shall, within seven days of taking
action under this clause, inform, in writing, the PCO Operator of the action taken
together with reasons thereof.
17.All the operations or actions of the PCO Operator or his employees or representative
with respect to operation of PCO will be subject to provision of Indian telegraph Act
1885 and Rules made there under, as amended from time to time, including any reenactment, notification, bye-Laws, Rules or directions issued or to be issued by
Government or Appropriate Authorities, as the case may be.
18.In case of any dispute arising between the PCO Operator and BSNL, the dispute shall
be referred to the sole arbitration of the General Manager Telecom or a person so
appointed by him to act as arbitrator on his behalf. Provisions of Arbitrations &
Conciliations Act 1996 or any Statutory Modifications or amendments/reenactments
thereof and the rules made there under and for the time being in force shall apply on
such arbitration proceedings.
19.The PCO Operator will display prominently a signboard of appropriate size indicating
the name and logo/Brand name of BSNL and the information prescribed by BSNL from
time to time.
20.The PCO Operator hereby guarantees minimum revenue generation, as prescribed by
BSNL from time to time, through calls made from PCO and in the event of revenue
generated from calls falling short of this minimum guaranteed revenue in a month,
undertakes to compensate BSNL to the extent of such shortfall.
21.The PCO Operator agrees to make payment of all bills regularly to BSNL by due date
and billing cycle specified by BSNL and in the case of non-payment of such bill or bills
or dues by the due date, the PCO(s) will be liable to be disconnected straight forth
without any notice.
22.Subject to the conditions mentioned in this agreement BSNL hereby agrees to charge
the PCO Operator on the basis of metered calls at the "defined rates" prescribed by
BSNL from time to time irrespective of actual collection by the PCO Operator from his
customers and the PCO Operator agrees to pay accordingly. The amount so arrived at
will be paid by the PCO Operator along with the applicable Service Tax and Cess. The
PCO Operator hereby authorizes BSNL to prescribe maximum limit of the price which
he/she can charge from his/her customers. BSNL may, at its sole discretion, revise such
maximum limit of price to be charged by the PCO Operator from time to time.
23.BSNL shall have full right to modify at any time the terms and conditions of the
agreement without any notice to PCO Operator. The PCO Operator agrees to abide by
the policy, Rules, Regulations & instructions of BSNL as revised/modified from time to
time, in respect of all matters including the amount of the security deposit, limits on call
charges to be charged from the public, defined rate payable by the PCO Operator etc.
24.This agreement is non transferable and BSNL’s mere acceptance of payment from a
person other than the PCO Operator will not amount to BSNL having transferred or
modified any of the terms and conditions of agreement and obligations to the PCO
Operator to such third party. The PCO Operator hereby agrees and undertakes to pay all
dues & outstanding to BSNL irrespective of whether bills for such dues or outstanding
are issued during the currency of agreement or on termination of agreement as case may
be, even if any dispute is pending between the PCO Operator & BSNL.
25.This agreement is made between the PCO Operator and GMTD ___________ shall be
deemed to have come into force on the day the PCO Operator starts operating the PCO
by using connectivity provided by BSNL on the basis of this application cum agreement
form and shall initially be valid for three(3) years. Further the said agreement will be
deemed to have been accepted by GMTD__________ if the PCO is sanctioned and the
connectivity from BSNL network is provided on the basis of this application as soon as
the said PCO is allotted by an officer authorized in his behalf.
26.BSNL shall not be liable for any Act of commission or omission of PCO Operator or
any third party/ Supplier/Manufacturer including any other service provider offering
any privilege or benefits to the PCO Operator.
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GMTD or Authorized Signatory on behalf of BSNL (Signature of the PCO Operator)
SEAL
PART-B (For office use only)
1. Application received on _________________________ 2. Registration No____________________ Date _______________
3. Cash receipt No.(in case of cash payment)__________Date _________ 4. Category allotted: (URBAN / RURAL) ___________________
5. Indicator No. allotted: ____________________________ 6. Selling agent / DSA Code : ______________________________
7. O.B.No. ________________________ Date _____________ 8. Date of activation of PCO ________________________________
Signature of authorized signatory on behalf of BSNL