MAHANAGAR TELEPHONE NIGAM LIMITED
ORDER - FORM FOR ISDN BRA

(Please read the instruction at the back before filling the form)
A. APPLICANT PARTICULARS
1. A. Title/Name of the Customer (Last name First)/Company/Firm/Organization
2. B. Name of Father/Husband/Group/Proprietor/Partner(s)
3. Existing working connections including Mobile: MTNL Nos. ………..
Others: ………
4. Complete installation Address
Flat/Plot No. Floor Building
Street Locality
City NEW DELHI Pin 1100
(Copy of Proof of Identity and Residential Address to be attached (see instruction 7)

5. Billing/Correspondence Address (if different from 4 above)
Flat/Plot No. Floor Building

Street Locality

City N E W D E L H I Pin 1 1 0 0

6. E-mail address (if any) ………………………………@…………..

7. No. of new connections required 8. Subscriber Category

9.Category: Residential Business Govt. PSU Statutory Body Any other

10. TARIFF PLAN OPTED :………………………

11. Whether subs.fitting (wiring) is required from MTNL Y/N

B. ADDITIONAL FACILITIES REQUIRED ( Tick whichever is required):
12. STD ISD Conferencing Call Forwarding Abbreviated dialling/Any other

13. Telephone instrument required: Normal CLIP Cordless with CLIP

Answering M/c Not required from MTNL
C.
Payment Details: DD/Cheque No. Dated
Drawn on :
Branch: .
D.
14. Telephone No. of subscriber/ DSA Code recommending you for MTNL connection
15. Your Contact No. : (State whether PP)
16. Old Tel No. of come back Sub., if applicable (See instruction 14)

DECLARATION

I 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 there under & Tariffs as amended from time to time. I am not a defaulter on account of non-payment of bills for any telecom service provided by MTNL. In the event of any dispute concerning any telecom line, apparatus or appliance, service, bill etc., between me/us and MTNL, the matter will be referred to the sole Arbitrator, appointed by a nominated authority in MTNL, and shall be governed by the provisions of the Arbitration and Conciliation Act. 1996.

Signature of Customer/Authorised Signatory

Signature of Customer/Authorised Signatory

Date :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ACKNOWLEDGEMENT/IDENTITY SLIP
(To be handed over by the applicant at the time of installation) (See instruction No. 12)
CA No.
Received from Shri/Smt. ………………………………………………………whose signature are given below, an application for new telephone connection

(Signature of MTNL Officer/Official)
(Signature of subscriber)
MAHANAGAR TELEPHONE NIGAM LIMITED
(O/O Executive Director,New Delhi-110001)

Contact Telephone No. (if any):

Please Specify the facilities required in case of ISDN Line (Tick mark)

CLIR CF ADC CUG MSN CH CLIP

(a) No. of Terminal proposed to be used: (Maximum of Eight ISDN terminals can be connected to NT 1)

(b) Type of Terminals proposed to be connected:

(i) Simple ISDN Handset Yes No

(ii) ISDN Feature Phone Yes No
(iii) ISDN PC Card Yes No
(iv) Terminal Adaptor Yes No
(v) G4 Fax Terminal Yes No
(vi) Video Telephone Yes No
(vii) Video Conferencing equipment
(This requires 3 ISDN Telephone Lines) Yes No
Form No. Regn. No. Exchange Date
Signaturr

INSTRUCTIONS FOR FILLING THE FORM FOR NEW ISDN BRI CONNECTION

1. The form may be filled up in Capital letters only.
2. In case of sole proprietary concern, proprietor may sign himself and affix rubber stamp.
3.In case of Partnership concern, all partners or any one of the partners duly authorised or Person with the Power of Attorney may sign. In case of Company, signature should be of a person on behalf of Company, in accordance with the provisions of its Articles of Association. In case of Partnership concerns, copy of (i) Power of attorney for authorisation & (ii) Partnership Deed and in case of Limited Company, a copy of the articles of association, may be attached.
4.In case of Govt. Departments, authorised person may sign and affix rubber stamp.
5.Submission of attested photocopies of any of the following documents shall be considered appropriate as proof of personal Identification and address, as the case may be.
Attestation by a Gazetted Officer, Bank Manager, Notary or any authority authorised would be acceptable. In case of difficulty in getting attestation the customer can bring originals with photocopies to the concerned Commercial Officer.
(i) Paid Telephone/Gas/Water/Electricity/Credit Card/House Tax bill receipt, allotment letter of accommodation issued by Estate Office of the govt. of India/Govt. of Delhi, NDMC/MCD/DDA.
(ii) Income Tax Returns.
(iii) Election Identity Card issued by Election Commission of India.
(iv) Driving License.
(v) Passport.
(vi) Rent Receipt of rented house.
(vii) Notarized personal affidavit on Rs. 10/- Non judicial Stamp Paper declaring the address and profession of the applicant.
(viii) rent/Lease agreement.
6. PAN number of the applicant.
7. If at any stage information furnished is found false - Telecom Service/Telephone provided is liable to be disconnected immediately without any notice
8. A copy of the present tariff structure is enclosed. Please specify the tariff plan to be opted in item 11 of the application form. The Plan for either voice or internet be indicated. The tariff applicable can be changed by MTNL without notice.