BHARAT SANCHAR NIGAM LIMITED logo.jpg (4773 bytes) 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
