APPLICATION FORM FOR A TELEPHONE CONNECTION

MAHANAGAR TELEPHONE NIGAM LIMITED, DELHI

APPLICATION FORM FOR A TELEPHONE CONNECTION

(Under Rule 414 of Indian Telegraph Rules 1951)
(Valid for one year form date of issue)

FOR OFFICE USE ONLY : (FOR NORTH-I ZONE ONLY)

Application No.   : -----------------------            (Please attach attested photo
Date of issue      : ------------------------            copy of PAN,I/Card issued by
C.A. No.       : -----------------------            Income Tex Deptt. or Form
Telephone Exch. : ------------------------            60 if PAN,I/Card is not issued.)

Note : Please read instruction before filling application form
1.Name of Applicant

Title(Dr.,Er.,Adv,etc)
Surname First Name Second Name

(Please leave one column blank between Surname, First Name and Second Name)
2. Name of Father/Husband/Guardian

Title(Dr.,Er.,Adv,etc)
Surname First Name Second Name

(Please leave one column blank between Surname, First Name and Second Name)
3. Category:(Tick in the appropriate box)

1. N.OYT-G

3. N.OYT-SS

5. OYT-G

7. TATKAL

2. N.OYT-S

4. N.OYT-SWS

6. OYT-S

8. ISDN

4. Dialing facility required:

1. Local Only

2. Local & NSD

3. Local & NSD & ISD

5. Purpose of use:

1. Residential

2. Business

3. Government

6.  Status of Applicant:-------------------      7. Concessional Group :-----------------
                          (see instructions)               (see instructions & attach supporting documents)
8.  Whether applicant shall provide wiring within his/her premises?

1. Yes

2. No

9. Whether applicant shall use his/her own Telephone Instrument?

1. Yes

2. No

10. Payment perticulars :
Ammount Rs.------------------- Mode of payment(Pay Order/DD/Cheque)------------------

Pay Order/DD/Cheque No. :

Dated:

                                                                                        Date, Month, Year
Bank & Branch : ------------------------------------------------------------------------

11.  Telephone Installation address :
House Flat No.                                Floor No.                                       Plot No.

Building Apartment Street/Road/Lane

Locality/Village/District City

12. Address of Correspondence:
House Flat No. Floor No. Plot No.

Building Apartment Street/Road/Lane

Locality/Village/District City

13. Existing Telephone No. (if any) Fax Number (if any)

Nearest telephone No.

14. Is there any telephone working in the name of the applicant any where in the country
(Yes/No) : Telephone Number

Address --------------------------------------------------------------------------------------

15. Telephone Installation address :
House Flat No. Floor No. Plot No.

Building Apartment Street/Road/Lane

Locality/Village/District City

16. If the application is for an EPABX junction,indicate if MAIN OR SUBSEQUENT--------
If SUBSEQUENT Indicate main telephone number

17. If the applicant is a Partnership Firm of Hindu Undivided Family(UHF),
please furnish the following :
Name is full of members of HUF/Partenership Firm           Father's Name           Relation to Karta
           ----------------------------                                   ---------------               -------------
           ----------------------------                                   ---------------               -------------
           ----------------------------                                   ---------------               -------------
18. Nominee
        Name :----------------------------------------------------------------------------
        Address :--------------------------------------------------------------------------
        Relation to applicant :-------------------------------------------------------
19. I/We hereby declare that in respect of the service provided againest the application ,
      I/We will abide by the indian Telegraph Rules as amended from time to time.

Date :
Place :                                                                               Signature of the Applicant(s)