BHARAT SANCHAR NIGAM LIMITED
(A Govt. of India Enterprise)

Application cum Agreement Form for allotment of Video Call Office (VCO)

Please fill the Form in CAPITAL LETTERS in black ink only.
(with STD code)
BSNL connection on which BB is working and VCO is required
Mobile No. :
(A) Applicant Profile :
Applicant Name
Gender : Male Female
(B ) Installation Address :

City
State
(C) E-mail ID :
(D) Select VVoBB Plan : Type of Applicant
i. Individual ii. Organisation
(E) Category of Applicant War Widow/Dependants Handicapped SC/ST
Ex. Serviceman Charitable Institution Hospital
Defence Establishment Par-Military Establishment Others
(F) Video Phone Model
PIN CODE
I/We declare and undertake that the above information is wholly true. I/We have read and understood the terms and conditions mentioned overleaf
in the Annexure forming integral part of this Application Form. I/We hereby agree to abide by them.
In case the transaction is through a Franchisee:
3) Category allotted : Urban Rural
2) It is further varified that customer is not having Broadband unlimited plan.
Signature
Name of Franchisee Franchisee Code and Stamp I / We hereby confirm that this form was signed by
subscriber in my / our presence and I/We physically
seen and verified the document(s)/Latest Bill
1) It is verified that customer is having BB Plan applicable for PCOs or to business customer.
Dated : ____/______/_________ Signature/Left thumb impression of the Seal of Company/Institution
Applicant (VCO Operator)/Authorized signatory) (if applicable)
(For Office Use Only)
Date: / /20
Account Number as printed in Customer's BSNL CDR bill
Date:
4) Application for VCO Plan received Date:
MAC Address of SIP Device: Sr.No
_______/_____/__________
Please call 1504 or 18002330999 in case of any difficulty / queries.
(Signature of BSNL Official)___________________________