ISP-IV

MAHANAGAR TELEPHONE NIGAM LIMITED,DELHI
APPLICATION FORM FOR LEASE LINE INTERNET ACCESS SERVICES
FOR HELPDESK USE
Commissioning Date .........................
LAN IP .......................................
WAN IP.................... Signature.......
FOR OFFICE USE ONLY
Password Reference No.-------------
Customer Code--------------
Booking Date-------------- Signature--------






Note:Please read the instructions & broad terms and conditions before filling up the form.
1.PERSONAL/COMPANY DETAILS

A) Name
                                               


B)Billing
                                               


Address
                                               


Pin
           

C) Contact Phone No.------------------              Fax No.-----------------------
(For informing account details)

D)Contact E-mail Address ------------------------------------------------

2.SERVICE OPTED :(Please tick your choice)

        Speed of port         Annual basis         Short Term
        64 Kbps         
        128 Kbps            
        256 Kbps                  N.A
        512 Kbps             
        1 Mbps                  N.A
        2 Mbps                  

2.2PAYMENT MODE:         Annual                 Quaterly        

3.TECHNICAL DETAILS:
A)Address where service required            ---------------------------------------------------------
                                                             ---------------------------------------------------------
B)Purpose of lease line                           ---------------------------------------------------------

4.ADDITIONAL IP ADDRESS REQUIRED :--------------------------- (Address)

5.DOCUMENT ENCLOSED:
1.Block Diagram of Setup                                Yes                 No        
2.Copy on relevant license agreement               Yes                 No        
3.Details of Modems being supplied to MTNL Yes                 No        

6.REBATE REQUESTED:----------------------- give documentary proof if any )

7.PAYMENT PARTICULARS:
DD Number ----------------- Date--------- Amount---------------
Bank Name-------------------------- Branch ---------------
I/We have carefully read the terms and conditions of the agreement and technical specifications of MTNL Internet access Services and agree to abide by the same.



Date:                                                                                       Signature of the Applicant




RECEIPT

Recieved from Mr./Ms-------------------------------------------------------------------------
Rs.-------(In words,Rs.---------------------------------------------------------------------)
Vide Cash/DD No.-------------------------------------- Dated------------------------------
Drawn on ---------------------------------------------------------(Bank's Name & Branch)


Customer Code/Ref. no.-----------------------                                                                 Signature


Note:1. Please quote your Customer Code No./Ref.no. for all future communications.



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