BHARAT SANCHAR NIGAM LIMITED (website address) FORM FOR TEMPORARY TELEPHONE CONNECTION Affix self signed passport size photograph (required for ISD facility only) Companies/ Organizations Individuals (tick appropriate box) (Please read the instructions before filling the form) 1. A. Title/ Name of the Customer/ Company/ Firm/ Organization (SURNAME FIRST) B. Name of the Joint Applicant, if any 2. Name of Father/ Husband/ Group/ Proprietor/ Partner(s) 3. PAN/GIR No: 4. Telephone No. working, if any: (Please see Instruction # 2) 5. Complete Postal Address House No Street/ Road/ Village Bldg./Appt. Area/ Locality/ Tehsil City/ District Pin 6. Billing/ Correspondence Address (if different from 5 above) 7. Period for which connection required: from___________ to________ 8. Purpose:__________________________ 9 Status of the Applicant: Individual Firm/ Company Government/ PSU 10. Grounds on which temporary Telephone is required : (for Medical Grounds, Medical Certificate issued by Registered Medical Practitioner to be attached) 11. Facilities Required (tick whichever is required) (please affix photograph for ISD facility) : STD ISD CLI Hotline Conferencing Call Forwarding Abbreviated Dialling 12.Whether Telephone instrument is required: Y/N 13. Whether Internal Wiring is required: Y/N 14. Payment Mode: Cash Demand Draft Amount Payment Details: DD No. Dated Drawn On: Bank Branch I hereby declare that information given above is true to the best of my knowledge and I will abide by the prevailing Telegraph Act/ Rules framed thereunder & Tariffs as amended from time to time. I am not a defaulter on account of non-payment of bills for any telecom services provided by any service provider. In the event of any dispute concerning any telecom line, apparatus or appliance, bill etc., between me/us and BSNL, the matter will be referred to the sole Arbitrator, appointed by a nominated authority in BSNL and shall be governed by the provisions of the Arbitration and Conciliation Act, 1996. Signature of Customer/ Authorized Signatory Signature of Customer/ Authorized Signatory Signed on: Date INSTRUCTIONS FOR FILLING THE FORM FOR TEMPORARY TELEPHONE CONNECTION ******************** 1. The form may be filled up in Capital letters only. 2. In the absence of PAN/GIR number, declaration in form 60/61 may be furnished in the enclosed proforma. 3. The temporary telephone connection can be sanctioned for a maximum period of six months only. 4. The subscribers of the temporary telephone connections are liable to pay double the normal rental charges in advance alongwith the application form. 5. They are also required to pay additional security deposit for STD/ ISD facility on temporary telephone connection.
