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

APPLICATION FORM FOR BROADBAND WIRELESS SERVICE (WiMAX)

(Please fill the application form in capital letters only)
YOUR DETAILS
1 The Name of the Customer/Company/Firm/Organisation (Surname First)
Mr Mrs Ms Dr Msrs
2 Date of Birth
3 Gender Male Female
4 PAN/GIR No. (In case PAN/GIR, is not there submit IT declaration in form 60/61)
( required in case if Individual)
5 Installation Address (Supported with Documentary Evidence-Refer Clause 2 overleaf) :
P I N
6 Billing Address (In case other than installation address) :
P I N
7 Purpose : Residance Business Govt PSU
8 Proof of Residential Address (Refer Clause 2 over leaf))
9 Proof of Photo Identity (Refer Clause 3 over leaf))
10 Contact No. Tele. Mobile
11 Email Address
12 Existing BSNL Customer Yes No
13 If Yes, Provide (a) Tel. No.
& Address
(b) Last Bill Payment Details Rs Date
CHOOSE YOUR PLAN
1 USO Plan : RWU 140 RWU 210 If any other, specify --------------------------------
2 CSC Plan : WCSC 400 WCSC 1000 WCSC 1500 If any other, specify --------------------------------
3 HOME Plan : HOWI 1000 HOWI 1800 If any other, specify --------------------------------
4 BUSINESS Plan : BUWI 4400 BUWI 8000 BUWI 12000 BUWI 20000 If any other, specify --------------------------------
5 Type of user : Single Multi User
6 Type of CPE required : Type 1 (Without WiFi) Type 1 (With WiFi) Out door USB Dongle
7 Bill Payment option : MONTHLY ANNUALLY
* (for details of plan please see BSNL website http://www.bsnl.co.in or BSNL WiMAX leaflet/pamphlet)
Signature of Customer/Authorised Signatory : Date :
FOR OFFICE USE ONLY
A Date of receipt of Application Received by
B Franchisee/DSA code
C AVCV by (Name) Signature
D CPE Make Model
E ESN CPE Service No.
F Date of activation
G BSNL Account Number
H CPE Label
Self sgined passport
size photograph of
Customer/ authorised
signatory
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I / We hereby declare that information given above is true to the best of my knowledge and I will abide by the prevailing Telegraph Act/Rules framed
thereunder & Tariffs as ammended from time to time.I/We am not a defaulter on account of non-payment of bills for any telecom services provided
by any service provider. I have read and understood the terms & conditions provided overleaf to the form for Broad Band Wireless Services and
accepted them as a binding on me. I/We have understood all rates, charges, tariffs and related terms & conditions at which telecommunications
services are provided by BSNL as applicable on this date and as ammended from time to time. I/We confirm that the information(s)/particulars
supplied by me is correct in all reaspect.
WiMAX