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MTNL Service Application Form

This document is an application form for various telecommunication services provided by Mahanagar Telephone Nigam Limited (MTNL), India's state-owned telecom services provider. The application seeks details such as applicant name, address, contact and identity details. It allows customers to choose from basic telephone and internet services including landline, broadband, IPTV, VoIP and mobile services. The form also collects preferences for billing options, tariff plans and value-added services. Required documents and payment mode are to be provided to complete the application process.

Uploaded by

Sneha Mishra
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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90 views1 page

MTNL Service Application Form

This document is an application form for various telecommunication services provided by Mahanagar Telephone Nigam Limited (MTNL), India's state-owned telecom services provider. The application seeks details such as applicant name, address, contact and identity details. It allows customers to choose from basic telephone and internet services including landline, broadband, IPTV, VoIP and mobile services. The form also collects preferences for billing options, tariff plans and value-added services. Required documents and payment mode are to be provided to complete the application process.

Uploaded by

Sneha Mishra
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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MAHANAGAR TELEPHONE NIGAM LTD

Jeevan Bharati Bldg Tower 1, 12th floor, 124, Connaught Circus, New Delhi 110001 Web Site Address: http://www.mtnl.net.in
BASIC SERVICE

Stamp size photograph (self signed)


GARUDA (CDMA)
PREPAID PREPAID

Internet TRIBAND DIALUP

IPTV
VOIP

GSM
DOLPHIN TRUMP

Video Conf
FWP

*1. Type of service required Please tick ( ) *2 Type of applicant: TITLE


*3.Name Mr Mrs Ms Dr *4.Father's/Husband's Name

LANDLINE ISDN

MOBILE POSTPAID POSTPAID

SURNAME

FIRST

MIDDLE

*5.Date of Birth(DD/MM/YY) (Date of incorporation in case of company) 8.Hobbies 9.Education 11.Average income per month(Rs) a) < 10,000 d) 30,000 -50,000 *12.Residential Address/ Installation Address (Proof to be attached ) 13. E-mail Id: 14.Billing Address (If different from above) Local Address (For outstation customers)
*15.A) PAN NO./ GIR NO. 16.Existing MTNL Tel No.(if any)

*6.Sex M / F

*7 Nationality 10.Marital Status Single Married

b) 10,000 -20,000 e) > 50,000

c) 20,000 -30,000

PIN CODE

PIN CODE ( If PAN No. not available please fill form 60)
Existing Customer A/C No.

17.i) Type of any other service of MTNL or other Operator used by you ii) Tel No of that service a) *18.Tariff Plan opted: Service(1)
Service(3)

b) Tariff Code Tariff Code


Service(2) Service(4)

Tariff Code Tariff Code

*19.Option for Receiving Bill *20. Option for Bill payment *21. Type & Model No of handset/Telephone instrument/Modem required 21(a) Whether subs. Fitting (wiring) is required from MTNL. Y/N *22. Any additional Value added services required _____________________________________________________________ 22.(a) Tariff Plan for value added service 23. NDNC Option: Yes No *24.Type of Identity proof submitted & its No.:
*25. Mode of payment for Registration: (EMI / Down Payment) Cash / Cheque / DD Rs.

Credit/Debit/Cheque/DD No. Bank account no. (in case of cheque) * Columns are mandatory

Date: Name of Bank & Branch on which Cheque /DD drawn

For office use Booked By Name of CSC/Distributor/MBA: Customer A/c Number CSC/Distibutor Code CDMA Handset Model

Landline /Mobile No./CDMA SIM No./ESN No. ------------------------------------------------------------Tear here --------------------------------------------------------------------------------------------------ACKNOWLEDGEMENT SLIP Received an application form for service from of Rs. in cash/through cheque/DD/credit/debit cards Signature & Name of MTNL officer with stamp Date: with the payment

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