BHARAT SANCHAR NIGAM LIMITED A P TELECOM CIRCLE APPLICATION FORM FOR INTERNET ACCESS SERVICES 3. Contact Name : _________________________________________________________________________ 4. Billing Address _________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Signature of Applicant ( 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:_______________________________________________________ Internet Application Form Page 2 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
