BHARAT SANCHAR NIGAM LIMITED
(http://www.bsnl.co.in)

MANDATE FORM
Subscribers authorization to pay telephone bills through Electronic Clearing Service(Debit)

1.SUBSCRIBER’S NAME(in block letters) : ------------------------------------------------
2.TELEPHONE NUMBER(S)* :
1)--------------------- 2)---------------------3)-------------------------
4)----------------------5)----------------------6)------------------------
3.PARTICULARS OF BANK
a)BANK NAME --------------------------------------------------------
BRANCH NAME &ADDRESS --------------------------------------------------------
b) 9 DIGIT CODE NUMBER OF THE BANK BRANCH:
(Appearing on the MCIR cheque issued by the bank. Please consult your banker)
c) ACCOUNT TYPE(S.B Account/Current Account/Cash Account):--------------------------
---
d) ACCOUNT NUMBER: --------------------------------------------------
e)LEDGER FOLIO : --------------------------------------------------
(if appearing on the cheque)
f) NAME OF THE ACCOUNT HOLDER: --------------------------------------------------
I/We here by declare that the particulars given above are correct and
express my/willingness to settle the payment of regular bi-monthly telephone bills
referred to above through participation in E.C.S of Reserve Bank of India,____ (Place)
and here by authorize Accounts Officer (TR) , ___________(Place) Telephones to raise
debits on such regular bi-monthly telephone bills as referred to above through this
scheme electronically for adjustment against my/our account In the event of my bank
being unable to debit my /our account for what so ever reasons, I/We will pay the bills
directly to ____________(Place) Telephones by cash. I/We will inform
_________(Place) Telephones any changes in my /our Bank Account. I/We have given today standing instructions to my/our Bank(copy
enclosed)
ADDRESS
-------------------------------------------------------------
--------------------------------------------------------------
The details Enclosed above are
correct as per our records.
Bank Stamp Authorized Signatory
-----------------------------
(Signature of Subscriber)
-----------------------------
(In case name of Subscriber
differs from that of A/c holder)
-----------------------------
Name of Account Holder
(In block letters)
STANDING INSTRUCTIONS
“Kindly accept any debit raised by RBI against my account no ----------------------
for telephone number/s -----------------, -----------------------, ---------------------,------------
-------,
--------------------- ,-----------------,------------issued to ---------------------------------
(Account Holder's Name)
by Bharat Sanchar Nigam Limited”.
------------------------------
(Signature of the Account Holder)