Internet Application Form

BHARAT SANCHAR NIGAM LIMITED

A P TELECOM CIRCLE
APPLICATION FORM FOR INTERNET ACCESS SERVICES

Application No:_______________________

To:
PGM/GM/TDM

.........................................Telecom District.

I/We wish to enroll myself/ourselves as subscriber of DOT Internet Access Service.The necessary Particulars are as follows:

1. Name of the Applicant___________________________________________________________________
    (Person/Organization)
2. Address where the connection is required__________________________________________________________________

    ____________________________________________________________________________________________________

   _____________________________________________________________________________________________________

Telephone No :

Fax No :

3. Contact Name : _________________________________________________________________________

Telephone No :

Fax No :

4. Billing Address _________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Signature of Applicant

USER NAME:
( 6 To8 characters )( PI.write in capital letters )

PASSWORD:
(6 To8 characters )( PI.write in capital letters )

( Please enter your username as you desire at login time )
This password is required for opening the connection.
The subscriber should change the Password on is own immediately.

INTERNET REFERENCE CARD

Regn No:__________________________________ Account Type:TCP/IP/Shell/leased

Name of the person/organization:_______________________________________________________

Contact Name & Telephone No:________________________________________________________

Date of provision:______________________________

User Name:____________________________________________________

Password:______________________________________________________

Address where the connection is required :______________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_____________________________________________ Telephone No:________________________________

Amount paid:_______________________________________

Demand Draft No:____________________________________

Signature of applicant

S.No	Date	Date of Renewal	Amount Paid	Password	Remarks
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