___________ Telecom Circle ____________ Telecom Distt. Circuit No. Allotted: APPLICATION FOR LEASED CIRCUITS (ONE APPLICATION PER CIRCUIT) From (Applicant) To _________________________ The Commercial Officer _________________________ O/o General Manager Telecom Date of Application______________ 1. The following Leased Circuit is required (Tick whichever is applicable) i) Voice circuit Telegraph Circuit Data Circuit Voice-cum-Data Circuit Non Exchange line Private Wire Junction (2 mbps) link for ISP service or any other service From (Complete Address____________________________________________ (A end) To (Complete Address) ________________________________________________ (B end) ii) Local -Intra City Intra SDCA Long Distance International iii) Temporary (mention period of hire: days/months) __________________ Permanent iv) Full Time Part Time (mention time periods) 2. The purpose for which the above circuit is required:Specify - i) Voice Data Telegraph Facsimile Circuit for Internet connection from BSNL Circuit for Internet connection from other ISP (Please give name of ISP) (Please tick more than one box if the circuit is to be used for more than one service) ii) Is the Internet circuit required to be terminated on private network Yes No 3. Please mention Telephone No(s) working at the premises at each end (A end)______________________ (B end)________________________ 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 5. Additional information in case of a data circuit i) Speed of operation ___________ Kbps/Mbps ii) Type & make of modem (if subscriber owned)______________________ (Enclose literature if the proposed model in not approved by TEC) iii) Type of circuit 2-wire/4-wire____________________________________ (Tick whichever is applicable) iv) Request of IP address: (Form A to be filled up) Note: IP addresses need to be utilized within 15 days of assignment. 6. General information required for any type of circuit. i) Whether the circuit is: Point to Point circuit Network Circuit (If it is a network circuit, diagram of approved network to be enclosed. If network approval in not available, please submit your application to _______________________O/o CGM ________________ Telecom Circle ______________________________________ (address). If already applied submit a copy of application. Application may be registered and demand note issued for payment. Circuit will be provided only after network approval is obtained.) Diagram enclosed Yes No Please mention the network approval reference number ______________________ __________________________________________________________________) ii) Hirer/main hirer of the circuit/network: (name & address)_____________________ iii) The following subscriber owned equipment is proposed to be used on the circuit and the concerned technical literature is enclosed. _______________________________ (Equipment connected on the circuit in addition to the modem/private automatic exchange/telephone instrument/relay set should be mentioned here) 7. The following additional equipment/attachments are required _________________________ 8. I/We desire to have General Manager ___________________________________________ as the controlling and billing authority. 9. Correspondence address & Name of contact person _________________________________ Fax ________________________________ E-mail ID______________________________ 10. Billing Adrress______________________________________________________________ 11. Any other relevant information the applicant wants to state. 12. List of circuits already working in India for our organization (Complete details of local/long distance circuits to be furnished. Please attach additional sheets, if necessary). A End B End CCt. No./Regn. No. Billing & Enrolling Authority at A end / B end and Telecom Unit-specify (Enclose separate list if space is not sufficient) 13. 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 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 are 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. 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 for 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. 15. Please mention list of enclosures: For Official use 1. Demand Note No.__________________________ Date __________________________ 2. Amount Rs _____________________________________________________________ 3. Mode of Payment : ______________ Cash/ Cheque (Cheque No________________ Date________) 4. Circuit No. Allotted._______________________________________________________ 5. Date of Commissioning____________________________________________________ 6. Frequency of payment (yearly/quarterly)____________________________________
