Serial No: ………………………

Thumb Print Premium Connectivity Limited Passport Size Photograph

(Not Mandatory)
IP Telephony Service Registration Form
Individual ☐ Corporate ☐ Prepaid ☐ Postpaid ☐
Concurrent Channels (Corporate): Credit Limit (Postpaid):……
Num. Connection (Corporate):….
IP Phone No: 0 9 6 4 8

1. Subscriber (Individual) / Authorized Person’s (Corporate) Name: ………..………………………………………………………………………..(BLOCK LETTER)

2. *Company/ Organization’s (Corporate) Name: ………………………………………………………………………………………………………………(BLOCK LETTER)

3. Email ID: …………………………………………………………………………. *Contact No: …………………………………………………………………………………...

4. *Nationality: Bangladeshi ☐ Foreigner ☐ *National ID/Passport No: ……………………………………………………………….

5. *Date of Birth: D D M M Y Y Y Y *Gender: Male ☐ Female ☐ Other ☐

6. *Permanent Address: Flat No: ……… House No./Name: ……………….. Road No./Moholla: …………………. *Area/Village: …………………………….

*Division: ……………………………………… *District: ……………………………….. *Upazila/Thana: …………………………………. *Post Code: …………….

7. *Present Address: Flat No: …………… House No./Name: ……………….. Road No./Moholla: ………………… *Area/Village: ………………...............

*Division:…………………………………….... *District: ……………………………….. *Upazila/Thana: …………………………………… *Post Code: ……………

8. Billing Address (*Postpaid): Flat No: …………. *House No./Name: ……………*Road No./Moholla: …….... *Area/Village: ………………...............

*Division:…………………………………….... *District: ……………………………….. *Upazila/Thana: ………………………………….. *Post Code: …………..

9. *Occupation: ☐ Government Service ☐ Private Service ☐ Business ☐ Student ☐ Other

10. Father’s Name: …………………………………………………………………………………………………………………………………………………………………………………………

11. Mother’s Name: ……………………………………………………………………………………………………………………………………………………………………………………….

12. Spouse’s Name (if married): ……………………………………………………………………………………………………………………………………………………………………..

13. Identifier: Name & Phone No: ………………………………………………………………………………………………………………………………………………………………….

National ID No: …………………………………………………………………………………………………………………………………………………………………………

14. *Attachments: (i) One copy passport size photograph (ii) National ID/Passport (For Non-Bangladeshi) photocopy

I do hereby declare that the information and data given above are correct. In case of any false information, I shall be liable to appropriate
legal action & I shall abide by the overleaf terms & conditions.

Applicant’s Signature Date Organization Seal

_______________________________________________________________________________________________________
Note: Any form without providing the information marked with asterisk (*) will be considered incomplete and will not be accepted.

Official Use only

Zone: ………………………………………………………………………………………………… IP Phone No: 0 9 6 4 8

Sales Representative’s Name: ………………………………………………………….. MAC:

Designation: ……………………………………………………………………………………… IP Address: …………………………………………………………………………
Signature & Date: No of Concurrent Channel (Corporate only): ………………………………..

………………………………………………………………………………………………………….. Date of Sale: D D M M Y Y Y Y

 Terms and Conditions
The subscriber as mentioned in the 1st page agrees to subscribe IPTSP services whether or not Subscriber has knowledge of or has authorized such
from Premium Connectivity Limited (hereinafter called ‘PCL’), providing such access or use, including, without limitation, claims for libel, slander,
services in Bangladesh subject to the following terms and conditions: invasion of privacy, infringement of copyright, patent infringement
(where Subscriber has used, connected, or combined the service with the
1. PCL shall provide and Subscriber shall avail the service as per the rules, products or services of others), negligence, or tortuous behaviour.
regulations, directives, instructions, terms and conditions of Bangladesh Subscriber agrees to indemnify PCL along with any parties from whom PCL
Telecommunication Regulatory Commission (BTRC) or any other authority obtains network service, and to hold them harmless from any claims
assigned by the Government of Bangladesh time to time. resulting from the use of the service by Subscriber or its users that
damages another party or violates the law.
2. This agreement shall be governed by the laws of Bangladesh and both
parties shall be in legal obligation to abide by the laws concerning this 11. The Subscriber shall pay the bill regularly within due date mentioned
agreement. in the bill (through account payee cheque in the name of “Premium
Connectivity Limited.” or through any other payment method as agreed
3. With the services from PCL, Subscriber shall not perform any illegal activity, with the Subscriber) in order to avoid interruption of the services. PCL
exchange any unauthorized information (such as copyrighted information for shall have the right to disconnect, suspend or bar the provision of the
which Subscriber has not received permission, information which is services to the Subscriber if bill is not paid within the due date mentioned
threatening or defamatory or obscene, etc.), send and receive any illegal voice in the bill. This right, however, shall not be deemed to have been waived,
calls, etc. Any such action may result in immediate temporary or permanent if PCL temporarily decides not to terminate the service under such
disconnection and PCL shall not be in any case responsible for any illegality condition. The Subscriber may be entitled to resume or reconnect his/her
carried out by its Subscriber. service by making payment of his/her outstanding bills in full.
12. PCL shall have the right to provide with any information including call
4. PCL shall be responsible for carrying the data packets (connection) only and recording/ details of the subscriber to the governmental, judicial or
is not responsible for its nature or content. Subscriber hereby declares and regulatory authorities, as and when required by the law of the land. PCL
undertakes that the service shall not be used for any immoral or unlawful or shall not have any obligation to provide any information to the subscriber
socially unacceptable purposes. in regards to such disclosure.
5. The services to be provided shall be exclusively to Subscriber and shall not 13. Both Parties may terminate this Agreement upon serving 30 days’
be transferred or reassigned to any other party except its users. prior notice unless there is any other notice period as agreed by both the
Parties
6. Subscriber assumes full responsibility and risk of using the service. The
service is provided on an "as is" and "as available" basis. PCL does not warrant 14. PCL may terminate this agreement immediately upon notice if
that any information, software or other material accessible via the service is Subscriber or any person who has access to the service through
free of viruses, worms, trojan horses, or other harmful components. PCL Subscriber’s account, commits a material breach of these terms and
makes no expressed or implied warranties, representations or endorsements conditions.
including but not limited to warranties of title, non-infringement or implied
15. Upon termination of this Agreement all rights granted to Subscriber
warranties of merchantability or fitness for a particular purpose regarding any
under this Agreement shall immediately cease and Subscriber must
merchandise, information, or service provided through the Internet.
return all equipment to PCL if provided by PCL. However, termination of
this agreement does not release Subscriber from any payment obligations
7. Services may be temporarily unavailable or limited because of equipment
such as but not limited to any accrued payments and/or any commitment
modifications, upgrades, relocations, repairs, unilateral disconnection of
for minimum subscription period as previously agreed by both parties.
uplink and/or down link by the BTRC and/or on request by law enforcing
agency or courts of law of the land and/or similar activities necessary for the 16. PCL shall have the right to disconnect, suspend or bar the services for
proper operation of Service. giving false information at the time of getting the connection or any time
thereafter with respect to subscription and/ or for changes in the given
8. PCL shall not be held responsible for non-performance or under- information, which is not informed to PCL. This shall be in addition to any
performance in case of Force Majeure events like government orders, civil other termination rights that PCL may have under this Agreement.
commotion, natural disaster, overhead fiber burn, electric pole break down,
service unavailability of upstream provider, any infrastructural break down of 17. PCL shall have the right to suspend/disable, delete/permanently
third party or other conditions or circumstances beyond the reasonable disconnect/retire the provision of the service to the subscriber when
control of PCL; nor shall PCL be liable for performance deficiencies caused or he/she reaches the different stages within the life cycle of a prepaid
created by Subscriber's equipment. subscriber’s account.
18. The subscriber shall be liable for or in respect of any damage or
9. PCL shall not be liable for any loss or damages arising directly or indirectly compensation payable under law in respect or in consequence of any
from the use of the service. It is solely Subscriber’s responsibility to evaluate accident or injury to any PCL workman or other person or damage to PCL
the accuracy, completeness, quality and usefulness of all opinions, advice, equipment or compensation/expense in case/suit incurred by PCL
services, and other information available through the use of service. resulting from any act or default of the subscriber.
Subscriber hereby releases PCL from liability arising from any content
accessed via the service. 19. Subscriber shall be under obligation to pay the VAT, SC and SD where
applicable.
10. PCL shall not be liable for any incidental, special, consequential, or 20. Any dispute will be settled amicably.
punitive damages of the Subscriber including but not limited to loss of profits,
loss of business or business opportunity, loss of use, etc. Subscriber shall 21. Both parties shall act in good faith and in best interest of each.
indemnify and hold PCL harmless from and against any loss, cost, claim,
liability, damages, or expenses (including legal fees) to third parties, relating
to or arising from the use of service by Subscriber, or any of their personnel,

I have read and understood the terms and conditions and voluntarily
accepts term as binding on me and hereby sign this agreement

Authorized Signature: Date: Customer’s Signature: Date: