MAHANAGAR TELEPHONE NIGAM LTD

Jeevan Bharati Bldg. - Tower 1,
12th floor, 124 Connaught Circus,
New Delhi - 110001

Web Site Address: http://www.mtnl.netin

Stamp size Photograph
(self signed)

*1.Type of service required
Please tick (v")
*2. Type of applicant : _
TITLE
ISDN
DOLPHIN TRUMp·
CIII.
LANOLINE MOBILE I POSTPAID PREPAID I
FWP I POSTPAID PREPAID I
SURNAME FIRST MIDDLE
*3. Name
*4. Father's/Husband's Name
*5. Date of Birth (DD/MMIYY)
(Date of incorporation in case of company)
*6.Sex M/F D *7. Nationality I
11.Average income per month (Rs) a) < 10,000 o
1 Single I Marriedl
c) 20,000 - 30,000 0
*8. Hobbies ---- *9. Educ·ation 10.MaritalStatus
b) 10,000-20,000 D
d) 30,000 - 50,000 0 e) > 50,000 0
*12.ResidentiaIAddressl ~
Installation Address
13.E-mail id:_______ ~ PINCODE
14.Billing Address
(Ifdifferent from above)
Local Address (For
outstation customers)
*15.A) PAN NO.JGIR NO. L-LI·_IL,I(If--,1PAN No.not available please fill form 60)
16. Existing MTNL Tel No. (ifany) Existing Customer AlC No.
17. i) Type of any other service of MTNL or other Operator used by you _
ii) Tel Noof that service a) b)
*18.Tariff Plan opted: Service (1) _ Tariff Code UTI Service (2) Tariff Code
Service (3) _ Tariff Code ITD Service(4) TariffCode
*19. Option for Receiving Bill _
*20. Option for Bill Payment _

*21.Type & Model No of handsetiTelephone instrument/Modem required _
*22. Any additional Value added services required ~
23. NDNC Option: I Yesl ~
*24.Type of Identity proof submitted & its No.: L-L
*25. Mode of payment for Registration: (EMI I Down Payment) Cash I Cheque I DO Rs. _
Credit/Debit/Cheque/DD No. ---;_ Date: _
Bank account no. Name of Bank & Branch on which Cheque I DO drawn _
(in case of cheque)
* Columns are mandatory. \
I Booked By Name of CSC IDistribut to_CSC IDistributor Code
Customer Alc Number 1 I COMA Handset Model
Landline IMobile No.ICOMA I I SIM No.1 ESN No.
--------------------------------------------------------------------------------------Tear here --------------------------------------------------------------------------------
Received an application form for service from with the payment
of Rs. in Cash I through Cheque I DO I Credit I Debit cards
Signature & Name of MTNL officer with stamp _ Date: _CUSTOMER DECLARATION / .uNDERTAKING:
I hereby declare and undertake that the above information iswholly true. I have read and understood the instructions and the terms &
conditions of MTNL for this service and agree to abide by them. I have gone through the details of the tariffplan, which I have opted
for, which I know, can change from time to time. I also agree that my connection is subject to verification, evaluation and acceptance
byMTNL.
* Signature ofSubscriber _
(Signature, name & seal ofAuthorized Signatory incase of Company)
* Received SIMlHandset
* Customer's Signature _
*Date:
Customer Guide
At SI. No 2 fill up type of applicant i.e. individual -- General (Gallantry I President's Police Medal for Gallantry awardees, War
widows, Disabled soldiers, Blind, Serving DOT employees, Retired DOT or MTNL or BSNL employees, Senior Citizen), Non
Residential telephone in Schools IUniversities I Institutions I Homes forAged I Orphans etc recognized by Government, a Private or
Public Company, Sole Proprietor orPartnership firm.
At S1.No 12 fill up'tileAdress where fixed connection is to be installed and I or where customer normally resides in case of mobile
connection. Customer has to submit proof of address for it.
At SI.No 14fill up the address where you want to receive the bill of the service. It is to be filled only ifinstallation address is different
frombilling address.
At SI. No 16mention existing telephone IMobile number &Customer Account No. ofMTNL, on which you want to get extra service
like Broadband, internet or other Value added service etc.
At S1.No 18please fill upTariff plan orTariffcode as given inour booklet for the service you want to avail. We have many alternative
tariff plans to suit indi1vidualrequirement. .
At SI.No 19Option tor Receiving Bill: Ifcustomerwants to receive the bill through e-inail write billthrough e-mail else leave it blank.
Kindly giveyouremail address at serial No 13.
At S1.No 20: Option for bill payment: If customer wants to pay the bill electronically please specify the mode of bill payment i.e.
through ECS/Credit/Debit card. Thetotal discount on both e-billing and e-payment combined together will not exceed more than Rs.
250. .
At Sl.No 21 Please fill up type I model of handset I telephone instrument I modem I setup box required by you. Details of available
handset are given inMTNL brochure.
At SI. No 22 Please fill up details of any additional or value added service you want to avail like ISD I STD I extra email ids I extra email space Iinternet I STD roaming IISDroaming ICURl VMS IGPRS IMMS IVideo Conferencing/ Games on Demand IVideo on
Demand I Fixed IPaddresses I Call forwarding IAbbreviated dialing I CLIP I any other. The details ofvalue added addresses are given
inMTNL brochure.
At SI.No 23 indicate your option forNational DoNot Call registry (NDNC).
At S1.No 25 forpayment option you want tochoose i.e. Down payment IEM! I Credit card IOnline payment
Instructions
(a) Please furnish the original documents with photocopies for verification of identity 'and address by one or more of the following
documents as applicable: (i)Income Tax PAN card (ii) Passport (iii) Voter LD. card (iv) Driving License (v) Armed License (vi) any
photo identity cards issued by a Statutory IGovernmentAuthority.
(b) Public Limited Coso may enclose certificate of Incorporation, Memorandum of Articles, duly signed by M.D. I Director of the
company along with any proof of identity.as .above of the authorized officer of the company. In case application is signed by an
authorized signatory, then attested photocopy ofPower ofAttorney must be attached.
(c) Incase of'Govt. oflndia Undertaking, Govt. ofIndia Offices I State GOVLOffices, the aforesaid requirements are dispensed with selfcertification on the letter head will suffice along with the name and designation of the coordinating officer to be consulted in case of
need.
(d) in case of Foreign Missions inIndia and other foreign agencies, the name and designation of the authorized officer along with details of
ofticials etc. for whOl~the connection isintended.
(e) in case of outstation subscribers, details oflocal reference(s) IAddress be given at Column (14) Billing Address I Local Address to be
given.
(f) Payment will be accepted by cashl DD/pay order in favor of "MTNLMumblli, Dolphin" for GSM services and "MTNLMumblli"
for any other service. . .
(g) For availing telephone under concessional category, requisite documentary proof has to be submitted along with application. Contact
our customer care executive orToll Free Helpline or website formore detail.
For more' details or any help visit our website http://mumbai.mtnl.net.in or Dial our Helpline
I Dial I . 1503
MTNL TRUSTUNE
we CUTIn DIGITAl SIGNS