(Please read the instruction
at the back before filling the form)
1. A. Title/Name of the
Customer (Last name First)/Company/Firm/Organization
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2. B. Name of
Father/Husband/Group/Proprietor/Partner(s)
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3. |
Existing working connections including Mobile: MTNL Nos. ………..
Others: ……… |
4. Complete installation
Address
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Flat/Plot No. |
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Floor |
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Building |
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Street |
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Locality |
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City |
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E |
W |
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E |
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Pin |
1 |
1 |
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(Copy of Proof of Identity
and Residential Address to be attached (see instruction 7)
5. Billing/Correspondence
Address (if different from 4 above)
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Flat/Plot No. |
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Floor |
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Building |
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Street |
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Locality |
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City |
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E |
W |
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Pin |
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1 |
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6. E-mail address (if any)
………………………………@…………..
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7. No. of new connections required |
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8. Subscriber Category |
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(See instruction 13) (Please write Code No. as indicated in
instruction No.10)
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9. |
Category: Residential |
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Business |
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Govt. |
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PSU |
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Statutory Body |
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Any other |
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10. TARIFF PLAN OPTED
(See instructions 9) :………………………
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11. Whether subs.fitting (wiring) is required from MTNL Y/N |
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B. ADDITIONAL FACILITIES REQUIRED ( Tick whichever is
required):
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12. |
STD |
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ISD |
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Conferencing |
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Call Forwarding |
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Abbreviated dialling/Any other |
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13. |
Telephone instrument required:
Normal |
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CLIP |
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Cordless with CLIP |
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Answering M/c |
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Not required from MTNL |
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C. |
Payment Details: DD/Cheque
No. |
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Dated |
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Drawn on : |
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Branch: . |
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D.
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14. Telephone No. of
subscriber/ DSA Code recommending you
for MTNL connection (Please see instruction 11) |
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15. |
Your Contact No. : |
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