___________ Telecom Circle ____________ Telecom Distt. APPLICATION FOR MPLS-VPN CIRCUITS (ONE APPLICATION PER VPN) From (Applicant) To _________________________ The Commercial Officer Date of Application______________ 1. Name of Company___________________________________________________________ 2. Contact Person ______________________________________________________________ Complete Address___________________________________________________________ Telephone No: ___________________ FAX No: ____________E-mail ID:______________ 3. Billing Contact _____________________________________________________________ Address for correspondance____________________________________________________ ___________________________________________________ E-mail ID:______________ Telephone No: __________________________ FAX No: ___________________________ 4. Status of the applicant: (please tick relevant item) i) Limited Co. ii) Public Sector undertaking iii) Government iv) Public Institution v) Statutory Body vi) Society/Trust vii) Others (Please specify) 5. Name of the cities where VPN is required. _______________________________ 6. Type of connectivity required: Mesh connected / Hub and spoke _____________ (In case of "Hub and spoke" connectivity, indicate Hub location also) 7. Application proposed on VPN : Data & file transfer Voice over IP Video Conferencing Video Streaming Any other (Please specify) 8. Attach VPN topology diagram : 9. Technical Contact ___________________________________________________________ Complete address____________________________________________________________ __________________________________Telephone No:___________________________ Fax ________________________________ E-mail ID______________________________ 10. Any other relevant information the applicant wants to state. 11. Technical information:-Fills in format attach at 'Annexure A' for each VPN site separately. 12. DECLARATION i) I/we hereby agree to abide by the provisions of Indian Telegraph Rules in force and as modified from time to time and such other terms and conditions prescribed by the telegraph Authority/BSNL. I/We agree that the circuit will be used purely for private/permitted application. It will not be used to carry voice/data or any other communication, which is not permitted by the rules of Telegraph Authority/BSNL. I/We further agree to extend facility to the Telegraph authority/BSNL in order to enable monitoring of the purpose, performance and operation of the circuit, as and when required. ii) I/We agree that necessary charges for registration/installation/Advance annual rental/Arrears if any will be paid to the controlling/billing authority. BSNL, __________________ Telecom District as and when we receive demand note. As and when such charges become due. iii) I/We agree that i/We shall pay the cancellation charges and other expenses incurred to establish the circuit as requested by me/us that may become payable, in the event of cancellation of the application/closure of the circuit at a later date. iv) I/we Agree to use the leased VPN circuit for the minimum period of hire as specified by the BSNL. v) I/We declare that the information filled up by me/us in the form is correct and no information has been withheld. If the information is found incorrect subsequently, BSNL will have the right to take any action deemed fit including denial/termination of service. vi) We have read and understood the term and conditions for provisioning of MPLS VPN. We also agree and to abide by the terms and conditions in force from time to time vii) BSNL reserves the rights to suspend/ disconnect the services without assigning any reasons. viii) Company will be responsible for payment of VPN charges in respect of all VPN sites. 13. Please mention list of enclosures: Place________ __________________________ Date________ __________________________ (Signature, Name & Address of the Applicant) 14. Important instructions for filling up of the form: i) The form may be filled up in Capital letter only ii) In the absence of PAN/GIR number, declaration in form 60/61 may be furnished in the enclosed proforma. iii) In case of sole proprietary concern, proprietor may sign himself and affix rubber stamp. iv) In case of partnership concern all partners or any one of the partners duly authorized or Person with the Power of Attorney may sign. In case of company, signature should be of a person on behalf of a Company in accordance with the provisions of its Articles of Association. In case of Partnership concerns, copy of (I) power of Attorney for authorization & (ii) Partnership Deed, and incase of Limited Company, a copy of the Articles of Association may be attached. v) In case of Government Department, Authorized person may sign and affix rubber stamp. vi) All sites of VPN must be in close user Group. The billing contact will ensure payment in respect of all billing sites. For Official use 1. Demand Note No.__________________________ Date __________________________ 2. Amount Rs _____________________________________________________________ 3. Mode of Payment : ______________ Cash/ Cheque (Cheque No________________ Date________) 4. VPN ID Allotted._______________________________________________________ 5. Date of Commissioning____________________________________________________ 6. Frequency of payment (yearly/quarterly)____________________________________ 7. Account Manager (with Name and Designations) BSNL NODAL OFFICER Annexure - A Technical information: i) ii) Name of City Complete address of contact person________________________________________ _____________________________________________________________________ __________________________________Telephone No:_______________________ Fax :______________________________E-mail ID :_________________________. iii) Complete address of locations where VPN is required _______________________ _____________________________________________________________________ __________________________________Telephone No:_______________________ Fax :______________________________E-mail ID :_________________________ iv) v) Application proposed on VPN site :-Application proposed on VPN : Data & file transfer Voice over IP Video Conferencing Video Streaming Any other (Please specify) vi) vii) viii) ix) viii) ix) x) xi) xii) xiii) xiii) Bandwidth Required ___________ Kbps/Mbps Type, make of modem and speed (if subscriber owned)______________________ Modem interface : G703/V.35 Class of Service: Gold / Silver/ Bronze (Tick whichever is applicable) Encapsulation Type: PPP/HDLC/FR/Ethernet (Tick whichever is applicable) Type of circuit 2-wire/ 4-wire____________________________________ (Tick whichever is applicable) Details Of Customer Edge Router along with interface type (Model no & Make):_______________________________________________________________ Whether Router support ISDN termination. ISDN Dial back up: Yes/ No (Separate application has to be filled for ISDN connectivities. ISDN connection and user charges will be payable separately.) Type of VPN required 1. L2VPN 2. L3VPN In case of L3 VPN, following additional information is to be furnished. xiv) L3VPN details: (This information can be worked out in close associations of BSNL representative) LAN IP Address / Subnet Mask:___________________ Routing Protocols: Static / Dynamic Specific requirement, if any__________________________________ For NOC Use: Port Allotted / Time Slot (For Channelized E1) _______________ WAN IP Address / Subnet Mask ________________ (Kindly furnish the above information for all sites of VPN in separate Annexures)
