BHARAT SANCHAR NIGAM LIMITED
(A Govt. of India Enterprise)
APPLICATION FORM FOR BHARAT FIBER NEW CONNECTION SERVICES (E-KYC Process)
www.bsnl.co.in | Help line : 1800 180 1503
1.Company/Organisation : UNIVERSAL MULTI STATE CAF No : BFCNC050224004435
Date of Onboard : 05/02/2024 15:32:27
Whether Existing Customer of BSNL if Yes,Provide account number :
2. Nationality : Indian
3. Name of Customer/Company/Firm/Organisation: UNIVERSAL MULTI STATE CO
4. Father/Husband/Group/Proprietor/Partner(s) :
Name of the Joint Applicant ,if any :
5. Gender : MALE 6.Date of birth :
7. PAN/GIR Or IT Declaration in Form 60/61, as applicable :
8. Indicator Number : 02385-266877
9. Contact Details , Mobile: 07350190379 Email ID: lokmudrauniversal@gmail.com
10.Fields to be captured/entered by Service Provider/Authorized representative
Service Type Service Sub Type Tariff Plan Applied*- Fixed Phone Number Destination Number
FIBRE BASIC-COMBO-FV-
BHARAT FIBER BHARAT FIBER VOICE 02385-266877
MONTHLY
BHARAT FIBER FIBRE BASIC-COMBO-FBB-
BHARAT FIBER 02385-266877
BROADBAND ANNUAL
Value Added Services Applied (if any) LOCAL,STD,CALL_FORWARDING,CALL_CONFERENCING,CLIP_FACILITY,
11. GOODS
Goods Type Name Model Name Vendor Name Acquisition Type
CPE CLIP CPE Customer Owned
CPE SINGLE_BAND_WIFI_ONT ONT Bundled WIFI ONT By Franchisee
12. Purpose : Residential
13. Installation address (where telephone is to be installed) :
Country : INDIA Detail Address
State : MAHARASHTRA House No./Flat No.:C/O S H HUDE
District : LATUR Village/City/Mandal :H NO 3-3-575 ANAND NAGAR UDGIR
Main Locality : UDGIR Road/Building :
Sub Locality: TQ. UDGIR Colony Name/Area :
Street Number : Landmark :
Pin Code : 413517 Additional Details :
14. Same as installation address, no need to display the Billing address attributes
15. Proof of identity details*:
Type of POI: Aadhar Card (Unique Identification Authority of India)
Date of Issue: 1970-01-01 Issuing Authority*:UIDAI GOI
Place of Issue: Document No.*:348389415890
16. Proof of address details* :
Type of POA:Electricity Bill
Date of Issue:1970-01-01 Issuing Authority*:MSEB
Place of Issue: Document No.*:622010310122
17. Name of Nominee, if any: UNIVERSAL MULTISTATE CO OP CREDIT SOCIETY
18. Payment Mode Cash/Demand Draft:
Amount : Bill Frequency :Monthly
Payment Details DD No. : Dated :
Drawn On Bank : Branch:
