Download Application form for Prepaid Connection

Pleasefilltheorderformincapitalletters.Fieldsmarkedin aremandatory.Deletethenon-selectedoptionstoavoidmis-useRed POSCode ActivationDate D?D?-?M?M?-?2?0 1. Applicant'sName 2.Gender 3.?NameofFather/Husband Male???Female Title????????????Name??????????????????????????????????????????Surname Name Surname Mr. LandMark(near/opposite/adjacent) 4.?Present Address(Attachvalidproofofaddressforverification)- ReferClause1(B)oftheInstructions 5.?PermanentResidential Address: Locality City Pin Contact TelNo(WithSTDCode). 6.?Documentssubmittedfor Nationality7.?DateofBirth 8. (ForForeigners) 12.MaritalStatus IdentityProof VoterId DrvLicense?????Passport??????PANCard?????PhotoCreditCard???Others AddressProof????VoterId DrvLicense?????Passport??????Electricity/Water/ TelephoneBill???Others Indian???Others?(Specify) 9.?PAN/GIR?No???????????????????????????????????10.PassportNo. 11.E-Mail-Id Single???????Married D??D?-??M?M?- Y Y Y Y 13. OutstationCustomers/ForeignNationals,providedetailsofLocalreference NameofLocalreference TelephoneNo. (Applicableonlytocustomersnothavingvalidproofoflocaladdress) Locality City Pin SignatureoftheLocalReference_____________________________________________ .Do YouwishtoregisterforDoNotCallRegistry Yes No?(ToregisterSMS-START DNDto1909(Tollfree))14 15.Customer'sDeclaration: SignatureofCustomer D??D??-??M?M??- Y Y2??0 Certified that I/ We have read and understood the terms and conditions provided overleaf to the form. I/ We have understood all tariff rates, charges and related terms and conditions at which telecommunication services are provided by BSNL as applicable on this date. I/ We further declare that the above information provided by me/ us is true and correct in all respects. I/ We hereby undertake to pay all charges raised on account of services subscribed. I/We am/ are aware that the SIM provided to me/ us is for my/ our bonafide use and is non- trasferrable & I/ We shall be responsible for its mis-use. I/ We am/are aware that obtaining a mobile connection with false documents or its mis-use would attract stringent action. I/ We also undertake that in the event this connection is used for any Telemarketing purpose, I/ We shall be solely responsible for registration of the connection with the mandated Statutory authorities. 16.DeclarationbyPointofSale(POS) 17.Declarationfor ActivationofSIM Certifiedthat a) The mandatory columns in Customer Acquisition Form has been duly filled. The customer acquisition form has been signed by the applicant in my presence. I have seen the applicant and matched the photo pasted on customer acquisition form with him/ her. The photocopy of identity & address proof has been matched and verified with the original with the applicant. b) In case of outstation customer/ Foreign national contacted the local referee on telephone and verified that he/she knows the customer stated in order form. SIMNo. LandMark(near/opposite/adjacent) Locality City Pin Contact TelNo(WithSTDCode). SignatureofDealer/BSNL Officialwith Name,StampandCode D?D??-??M?M??- Y Y2??0 Certified that all necessary documents are in order including that the signature on the self-attested photo match with the signature on the application form and the photo on the CAF matches the one on the photo ID document, before activating the SIM . Y Y SignatureofFranchisee/BSNL OfficialwithName,StampandCode D?D??-?M?M??- 2??0 BHARATSANCHARNIGAMLIMITED (A Govt.ofIndiaEnterprise) Jammu&Kashmir TelecomCircle Orderfor GSMMobileConnectionPre-Paid BSNL No. Affixpassportsize photograph (Selfsigned) No. A - Regd.Office:BSNL SancharBhawan,Janpath,NewDelhi-11001Website:www.bsnl.co.in Contd.onpage2 INTERNETDOWNLOADED MobileNo. BHARATSANCHARNIGAMLIMITED (A Govt.ofIndiaEnterprise) Jammu&Kashmir TelecomCircle Contd.frompage 1 18Serviceordered 2G 3G 19Planordered??Genl1P/sec????Genl All@49p????Humrahi Othersspecify VoicePlan?????DataPlan 20Facilityordered???Local????????N ISD NationalRoaming OthersspecifySD GPRS 21. a)MyMobileHandsetdetails:Make????????????????????????Model????????????????IMEINo. b)MyBank A/cDetails:BankName????????????????????????????????????????????Branch AccountNo.?????????????????????????????????????????????????Natureof Account???????Savings?????????????Current c)MyCreditCardDetails:CardNo???????????????????????????????????????????????????ValidUpto - -?2??0 d)MyVehicleMake?????????????????????????????????????????????RegistrationNo. Applicant'sotherinformation D?D Y YM?M 22) a)Occupation??????????????????????????????????b)PreferredLanguage?????????????????????c)Interest OtherInformationtohelpyouservebetter Yes??????No S.No.?????????????????MobileNo.?????????????????????????????????NameofServiceProvider i ii Yes??????No S.No.????????????MobileNumber??????????????????????????NameoftheFamily????MonthlyIncome????Relationshipwiththe Member?????????????(InRs.)???????????applicant i ii iii iv v Note:Customershouldaddaseparatesheetincasehe/shehasmorethan5telephonenos.inhis/hernameand/ornameofhis/her?familymembers. 23) a)?Doyouhaveanyotherworkingmobileno.inyournameatPresent b)?If Yes,indicatetheworkingmobilenumbersinyourname: c)Statereasonsfortakingsecondormorethantwoworkingmobileconnectionsinyourname: 24)Do Youhaveanyotherworkingmobiletelephoneno.inyourfamilyatpresent 24.1If Yes,indicatetheworkingmobilenumbers(bothPre-paidandPost-paid)inthenameofyourfamilyatpresent . DeclarationFormformultipleconnections(MorethanOneconnectionforapplicantand/orhis/herfamily) SignatureoftheCustomer Form60(Seethirdprovisiontorule114B) FormofDeclarationtobefilledbyapersonwhodoesnothaveeitheraPermanent AccountNumberorGeneralIndexregisternumberandwho makespaymentincashinrespectoftransactionspecifiedinclauses(a)to(h)ofrule114B. 1.Fullnameandaddressofthedeclarant 2.Particularsof Transaction???????????????????????????????????????????????????????3. Amountof Transaction 4. Areyouassessedto Tax? Yes/No 5.If, Yes i)DetailsofWard/Circle/Rangewherethelastreturnofincomewasfilled? ii)reasonsfornothavingPermanent AccountNumber/GeneralIndexregistrationnumber? 6.DocumentsbeingproducedinsupportofaddressinColumn(1) - Signatureofthedeclarant-??2??0D?D M?M Y Y Regd.Office:BSNL SancharBhawan,Janpath,NewDelhi-11001Website:www.bsnl.co.in Certified that I have made the entry of CAF details in Database ) (ForOfficeUseonly)????????????????????????????????????????????(ForOfficeUseOnly) 25 CertificateforEntryofCAFinDatabase 26)CertificateforVerificationofDatabaseentriesofCAF Certified that I have verified the entries of database with C?A?F & s u p p o r t i n g documents SignatureofBSNL Employee Name StaffNo. - -??2?0D?D M?M Y Y SignatureofBSNL Employee Name StaffNo - -?2?0D?D M?M Y Y TERMS&CONDITIONS 5.3 All discounts or other special benefits announced byBSNLfrom time to time shall have the time limitation. BSNL shall have the right to withdraw/ vary/ extend any/ all such discounts, etc. at any time without notice. 5.4 Aservice tax as applicable shall be levied on all charges payable by the customer. 6.1 BSNLshall be at liberty to provide theGSMservices under any brandname. 6.2 BSNL reserves the right to seek/ verify financial and other information whom customer's Banker/ Credit provides and such other sources and reserves the right to reject subscription even after activation for any reasons without liability. 6.3 In case it is found that the information furnished in the order form is incorrect/ false and/ or the document enclosed are not truthful/ genuine, the telephone services provided are liable to be withdrawn immediately without any notice. In addition action may be taken by Police / Security agencies asdeemed fit. 6.4 The information provided by customer in the order form and/ or subsequent forms and/ or collected/ gathered by BSNL shall be property of BSNL even if application is rejected/ refused and/ or connection is disconnected. BSNL may use the said information in anymanner, if deems fit. 6.5 BSNL will not be liable to the customer for any loss of business, profit, revenue or goodwill, anticipated savings use of contracts or for any indirect or consequential loss howsoever it arises. 6.6 BSNLshall not be liable for any delayed activation. 6.7 BSNL will not be liable for any dealings for the customer with any party which is not authorised to deal on its behalf. 6.8 BSNL is not responsib le for the acts of Franchisees/Business Associations/Distributors/Channel Partners/Dealers/Retailers with regard to the scheme which are not authorised byBSNLor which are purported to have been offered on behalf of BSNLwithout the latter's sanction. 6.9 BSNL shall not be responsible for any civil or criminal liability incurred by the customer due to misuse of the service provided by BSNL i.e. any acts of commission or omission by the customer. 6.10 BSNL shall not be liable for any act of commission or omission of any third party/suppliers/manufacturers including any agency/company offering any privilege or benefits to customer without specific permission or authority of BSNL. 6.11 BSNL will not be held liable in case GSM Mobile services are affected outside its control viz. Atmospheric conditions, Structures (Building/ Bridges) & proximity of Base Stations, acts of God or any other Force Majeure conditions. :- 7.1 The scope of cellular services is governed by the statutory guidelines issued by the Telecom Regulatory Authority & Govt. of India within the parameters of licence agreement executed with the Ministry of Communications, Govt. of India. The cellular phone services are governed by the Telegraph Act, 1885 and the Indian Telegraph Rules, 1951 framed under the same act, as amended from time to time and the customer shall abide by them. 7.2 BSNL is entitled to change, vary, add, withdraw any services/additional services, supplementary services, etc. and or change, vary, add, alter, delete, withdraw any/all charges/prices/discounts/surcharges, etc. related thereto including equipments, accessory(ies) and/or prices thereto etc. at any time in its sole discretion for one or more or all customers. 7.3 BSNL will test the equipment prior to activation & customer shall ensure its functionalities thereafter. BSNL shall not be responsible for any of the defect/ fault etc. which is not expressly covered by the manufacture of the equipment. 7.4 Any repairs/ exchange carried out by BSNLat the request of customer for defects, etc. shall be charged from the customer as perBSNLpolicy on the subject from to time. 7.4.1 In case of suspension/ disconnection etc. reconnection may be made by BSNL in its sole discretion on such additional terms asBSNLmay determine. 7.5 BSNL may at any time suspend without notice and without any liability the service wholly or partially and/or disconnect any customer equipment from the network for any reason which is found to be reasonable by BSNL including any of the following circumstances. a) Due to any discrepancy noticed in the material particulars provided in the form overleaf including address confirmation. b) During technical failure, modification or repair or testing or the Network. :- 8.1 All such dispute & differences that may arise between the parties hereto as to the meaning, construction or effect of the terms & provisions of this agreement or as to the right or claim of the either party under this agreement shall be referred to the sole arbitration of Chief General Manager Telecom, BSNL J & K Circle or his nominee including any officer/ executive of BSNLnominated by him. 8.1.1 The customer will not raise any objection in any such appointment that arbitrator so appointed is employee of theBSNL. 8.1.2 The same will be settled by Arbitration conducted in accordance with the Provisions of Arbitration and Conciliation Act, 1996 or any statutory modification or re-enactment thereof or any rulesmade thereof. 9.1 Any notice pursuant to this agreement shall be deemed duly given or made when they have been delivered by regd. Mail/ FAX/ by hand addressed to the party at the address set forth at the beginning of this agreement or to such other address as has been given to the other party in writing. 10.1 The Courts at the headquarter of J & K Circle viz. Jammu shall have exclusive jurisdiction under this agreement. I confirm that I have read the terms& conditions and agree to abide by them. 6. Duties& Responsibilitiesof BSNL:- 7. Services 8. Dispute Resolution/ Arbitration 9 Notice :- 10 Litigation:- Signatureof Customer On acceptance of duly signed Order form for pre-paid GSM Mobile Connection (hereafter called as "Pre-Paid GSM") from customer by BSNL, an agreement is hereby formed between the customer, named in the order form (hereinafter referred to as the "Customer") of the one part and Bharat Sanchar Nigam Limited having its Circle office at 4 Floor, North Block, Bahu Plaza, Jammu- 180 012 and having its RegisteredOffice at Bharat Sanchar Bhawan, Janpath, New Delhi 110 001 (hereinafter referred to as "BSNL-J&K") of the other part The customer has been provided with the details of different plans/ Schemes including applicable call charges & tariff. The customer has understood the same & exercised his choice accordingly. BSNLhas already provided a SIM Card along with PIN (Customer's security code) and a personalised telephone number to enable the customer to use GSM services of BSNL in its licensed geographical areas. Now it is hereby agreed by&between the parties: 1. Period ofAgreement: - 1.1 This agreement will come into effect from the date of signing of the terms & conditions and/ or activation of SIM whichever is later & shall be valid unless terminated by either of the party. 1.2 The agreement period shall be limited to the validity date of the license of BSNL-J&K for the operation of cellular mobile telephone service in the J&K state along with its extension as received from time to time from the licensor i.e. Department of Telecommunications, Ministry of communications, Government of India. It is also subject to all applicable laws, bylaws, rules, regulations, notifications, orders, directions of the Government (Centre& State) / Local Municipality/ Court/ Tribunal. 1.3 BSNL reserves the right to terminate the subscription of any customer who is not competent to enter into any contract under the Indian ContractAct, 1872. 1.4 Except as provided elsewhere either party may end the agreement by written notice giving not less than 30 days to other party but such a notice shall not absolve the customer of its liability to make payments of the accounts that may be due and outstanding on the date of such notice or asmaybecomedue subsequently. 2. The said SIM card of personalised telephone number shall remain exclusive property of BSNL. The customer is licensed to use it to obtain access to the network during the Agreement period only and shall return the same to BSNL upon the termination/ determination hereof and/ or upon disconnection of service. 2.1 BSNL connection/SIM card shall be non-transferable in nature. Any private transfer effected by the customer shall not absolve the customer of his primary duty towards a) BSNL for usage charges levied pertaining to such particular connection/ SIM card and/ or b) Proper usage as envisaged under Clause 7.1. 2.2 BSNL's acceptance of payment from a person other than the customer shall not amount to BSNL having transferred or modified any or rights & obligations to the customer to such third parties. 2.3 For addition/ deletion/ change in any supplementary services/ plan / scheme/ features, customer shall submit order in the requisite form and shall be bound by the additional terms thereof. 2.3.1 Any withdrawal/ change in supplementary services/ plan / scheme/ features shall entitle the customer to adjustment/ refund of the money already paid as per applicable terms& conditions. 2.4 After 90 days of deactivation of the GSM Mobile service, BSNL reserves the right to allot the telephone no. to another Customer. The customer shall not have any right on the saidGSMmobilenumber. 2.5 The warranty of SIM card shall be six months from the date of its purchase. The faulty SIMs during the warranty period shall be replaced byBSNLfree of charge. 2.5.1 The faulty SIMs beyond warranty period shall be replaced against charges as applicable for issue of duplicate SIMcard. : - 3.1 The Customer hereby agrees that a) He will not use the GSM Mobile telephone connection/ service for any unlawful/ illegal/ immoral purposes. b) He will not use improper/ abusive/ indecent/ threatening/ harassing language on the GSMMobile telephone connection. c) He will not send obscene, indecent, threatening, harassing, unsolicited messages or messages affecting/ infringing national interest to create any damage or risk to BSNL or its equipment/ network and/or other customers. 3.1.1 In case of failure to observe above conditions, BSNL reserves the right to disconnect service without liability, at its sole discretion. 3.2 The Customer will be responsible for safe keeping of SIM provided to him to gain access toGSMmobile network of BSNL. 3.2.1 In case of loss of SIM card by the customer, the same shall be reported to BSNL at the earliest. 3.2.2 The liability arising from the unauthorised use/ misuse of SIM card shall be borne by/ lie on the customer. 3.2.3 On request from the customer, BSNL shall issue duplicate new SIM card against charges as set out in the tariff schedule from time to time. 3.3 The Customer will provide all information and cooperation to BSNL that BSNL may reasonably require from time to time. 3.4 The customer hereby agrees to indemnify and hold BSNL harmless against any claim against BSNL for libel or slander arising out of communications sent or received by customer on BSNL's network. The customer shall also indemnify BSNL for any claim against BSNL arising out of any infringement or violation of copy right by the customer or by anyone else using the mobile connection of the customer. 4. Privacy of communication is not guaranteed which is subject to Regulation of the Government. 4.1 BSNL may withdraw/ add/ change/ vary any services/ supplementary services/ scheme/ plans etc. and /or to vary the terms and change at any time in compliance with the directions of the Govt. agencies. :- 5.1 The rates/ charges may change as per the directives of TRAI/ any statutory authority from time to time. 5.2 Any increase/addition/introduction of taxes and/or levy of taxes, duties or any other statutory charges, etc. in future shall be to the customer's account. No separate notice will be issued to him in this regard and thesame shall bedeemed to be part of tariff. th 3. Duties& Responsibilitiesof theCustomer 5. Charges WitnessForm&WitnessVerificationForm a)CertifiedthattheapplicantintheorderformMr/Mrs.?????????????????????????????????????????????????is residingatthestatedaddressandispersonallyknowntomeforlast????????????????????yearsand monthsandhis/hersignaturesontheorderformareattested. NameoftheWitness Addressofwitness Regularrevenuepaying TelephoneNo.ofWitness(morethan3monthsold) - -??2??0 SignatureofWitness b)Genuinenessofcertificateofwitnessabovehasbeenpersonally/telephonicallyverifiedwithwitnessonabove mentionedtelephonenumberon??????????????????????????????at????????????????????andfoundtobe correct. - -??2??0 Franchisee/BSNL Employee Name,Signature&Seal. VerificationForm D?D M?M Y Y D??D M??M Y Y 1.NameoftheSpouse 2.DateofBirthofSpouse 3.Weddingdate 4.Spouse's TelephoneNo. AdditionalInformation(Optional) FormNo.61ofIncomeTaxRules,1962 Verification Form of declaration to be filled by a person who has agricultural income and is not in receipt of any other income chargeable toincome tax in respect of transactions specified in clauses 9(a) to (g) of Rule 114B 1. Full name and address of the declarant 2. Particulars of transaction: 3. Details of documents being produced in support of address in Column (1) Yes/No I hereby declare thatmy source of income is from agriculture and I amnot required to pay IncomeTax on any other income if any. Date: / / 20 Signature of declarant/ Customer I do hereby declare that what is stated ab is true to the best ofmy knowledge and belief. Verified today, the day of 20 Place Signature of declarant/ Customer: Acknowledgement ( )ofPre Paid GSM Mobile Connection OrderForm FormNo.:............................................... Nameof Applicant:........................................................ ................................................ . Address:.............................................................................................?????............................................. .........................................................................................................................?????.................. . ModeofPaymentCash/D.D.No.:............................................. ...............?????.................... . .................................. . S/oW/oD/o........ ........... .......... Drawnat.???????.......... Amount Date......................................... SignatureofthereceivingDealer/BSNL officialwithseal