BHARAT SANCHAR NIGAM LIMITED (http://www.bsnl.co.in) MANDATE FORM Subscribers authorization to pay telephone bills through Electronic Clearing Service(Debit) 1.SUBSCRIBER'S NAME(in block letters) : ------------------------------------------------2.TELEPHONE NUMBER(S)* : 1)--------------------- 2)---------------------3)------------------------4)----------------------5)----------------------6)------------------------3.PARTICULARS OF BANK a)BANK NAME ------------------------------------------------------- BRANCH NAME &ADDRESS ------------------------------------------------------- b) 9 DIGIT CODE NUMBER OF THE BANK BRANCH: (Appearing on the MCIR cheque issued by the bank. Please consult your banker) c) ACCOUNT TYPE(S.B Account/Current Account/Cash Account):------------------------- d) ACCOUNT NUMBER: -------------------------------------------------- e)LEDGER FOLIO : ------------------------------------------------- (if appearing on the cheque) f) NAME OF THE ACCOUNT HOLDER: ------------------------------------------------- I/We here by declare that the particulars given above are correct and express my/willingness to settle the payment of regular bi-monthly telephone bills referred to above through participation in E.C.S of Reserve Bank of India,____ (Place) and here by authorize Accounts Officer (TR) , ___________(Place) Telephones to raise debits on such regular bi-monthly telephone bills as referred to above through this scheme electronically for adjustment against my/our account In the event of my bank being unable to debit my /our account for what so ever reasons, I/We will pay the bills directly to ____________(Place) Telephones by cash. I/We will inform _________(Place) Telephones any changes in my /our Bank Account. I/We have given today standing instructions to my/our Bank(copy enclosed) ADDRESS -----------------------------------------------------------------------------------------(Signature of Subscriber) (In case name of Subscriber differs from that of A/c holder) The details Enclosed above are correct as per our records. Name of Account Holder (In block letters) Bank Stamp Authorized Signatory STANDING INSTRUCTIONS "Kindly accept any debit raised by RBI against my account no --------------------- for telephone number/s -----------------, -----------------------, ---------------------,------------------, --------------------- ,-----------------,------------issued to -------------------------------- (Account Holder's Name) by Bharat Sanchar Nigam Limited". (Signature of the Account Holder)
