*1.Type of service required

Please tick (/;

MAHANAGAR TELEPHONE NIGAM LTDJeevan Bharati Bldg. -Tower 1 , 12'n Floor, 124 Connaught Circus, New Delhi - 1 1OOO1

Website Address : http:/lwww.mtnl.net.in

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MOBILE I POSTPAIDI PREPAID

FWP POSTPAID IPREPAID

*2. Type of applicant

TITLE SURNAME FIRST MIDDLE

Name Fil'il;F;lFather's/Husband's Name

Date of Birth (DD/MM^/Y) l-T-l -T-T-fl(Date of incorporation in case of company)

*6. Sex M/ F

*8. Hobbies *9. Education Marital Status t-SinGTl/arriedlc) 20,000-3O,OO0 f]

10.

nn*1 2.Residential Address /

lnstallation Address

13.E-mail id:

l4.Billing Address(lf different from above)LocalAddress (For

outstation customers).15.A)PAN No./GlR NO. lf PAN No. not available please fillform 60)

l6.Existing MTNL Tel. No. (if any)

17.i)Type of any other service of MTNL or other Operator used by you

ii) Tel No of that service a)

*l B.Tariff Plan opted:

*3.

*4.

"5.

11. Average income per month (Rs) a) <10,000

d) 30,000 -50,000b) 10,000-20,000

e) >50,000

Service (1)

Service (3)

Tariff Code Service (2)

Tariff Codel I I I Service(4)

Tariff Code

Tariff Code*19.Option for Receiving Bill

*2O.Option for Bill Payment

"21.Type & Model No of handset/Telephone instrument/Modem required*22.Any additional Value added service required

23.NDNC option E N*24.Type of ldentity proof submitted & its No.:

*25.Mode of payment for Registration: (EMl/

CrediVDebiVCheque/DD No.

Bank account no. Name of Bank & Branch on which Cheque / DD drawn

(in case of Cheque)

*Columns are mandatory

Down Payment) Cash / Cheque / DD Rs.

Date:

tltl

Booked By Name of CSC/Distributor / MBA: CSC / Distributor Code

Customer A/c Number

'":.::""1'"::]'*".1"o'o-":'*o.1=.**".

Received an applicant form for service from

of Rs. ln Cash / through Cheque / DD /Credit / Debit cards

Signature & Name of MTNL officer with stamp

Kwality Prints /O2-2O11 / Qty: 4,00,000 Nos.

with the payment

CUSTOMER DBCLARATIOI\ / {.INDERTAIilI{G :

I hereby declare and undertake that the above information is wholly true. I have read and understood the instructions and the terms &conditions of MTNL for this service and agree to abide by them. I have gone through the details of the tariffplan, which I have opted

for, which I know, can change form time to time. I also agree that my connection is subject to verification, evaluation and acceptance

byMTNL.

* Signattre of Subscriber

*Received SlM/Handset*Customer's Signature*Date:(Signature, name & seal ofAuthorized Signatory in case of Company)

Customer GuideAt SI. No. 2 fill up type of applicant i.e. Individual - General (Gallantry / President's Poiice Medal for Gallantry awardees, War

widows, Disabled soldiers, Blind, Serving DOT employees, Retired DOT or MTNL or BSNL employees, Senior Citizen), Non

Residential telephone in Schools / Universities / Institutions / Homes for Aged / Orphans etc recogni zedby Government, a Private or

P ublic Company, Sol e Proprietor or Partn ership fi rm.At SI. No. 12 fill up theAddress where fixed connection is to be installed and / or where customer normally resides in case of mobile

connection. Customer has to submit proof of address for it.At SI No. 14 fill up the address where you want to receive the bill ofthe service. It is to be filled only if installation address is different

frombiltring address.

At SI No. 16 mention existing telephone / Mobile number & CustomerAccount No. of MTNL, on which you want to get extra service

like Broadband, Internet or otherValue added service etc.

At SI. No. 1 8 please fill up Tariffplan or Tariffcode as given in our booklet for the service you want to avail. We have many alternative

tariffplans to suit individual requirement.At SI No. 1 9 Option for Receiving Bill: If customer want to receive the bill through e-mail write bill through e-mail else leave it blank.

Kindly give your email address at serial No. 13 .

At SI No. 20: Option for bill payment : If customer wants to pay the bill electronically please specify the mode of bill payment i.e.

through ECS/Credit/Debit card. The total discount on both e-billing and e-payment combined together will not exceed more than Rs.

250.At SI No. 21 Please filIup type lmodel of handset / telephone instrument / modern / setup box required by you. Details of available

handset are given inMTNlbrochureAt SI No. 22Please frll up details of any additional or value added service you want to avail like ISD / STD extra email ids / extra e-

mailspace/internet/STDroaming/ISDroaming/CLIR/VMS/GPRS/MMS/VideoConferencing/GamesonDemand/Videoon Demand / Fixed IP addresses / Call forwarding /Abbreviated dialing / CLIP / any other. The details of value addecl addresses are

giveninMTNlbrochureAt SI No. 23 indicate your option forNational Do Not Call registry NDNC).At SI No. 25 for payment option you want to choose i.e. Down payment / EMI / Credit card / online payment.

Instructions

Please furnish the original documents with photocopies for verification of identity and address by one or more of the following

documents as applicable: (i) Income Tax PAN card (ii) Passport (iii) Voter I.D. card (iv) Driving License (v) Armed License (vi) any

photo identity cards issued by a Statutory / GovernmentAuthorityPublic Limited Cos. may enclose certificate of Incorporation, Memorandum of Articlos, duly signed by M.D./Director of the

company along with any proof of identity as above of the authorized officer of the company. In case application is signed by an

authorized signatory, then affestedphotocopy ofPower ofAttorney mustbe attached.

In case of Govt. of India Undertaking, Govt. of India Offices / State Govt. Offices, the aforesaid requirements are dispensed with

self-certification on the letter head will suffice along with the name and designation ofthe coordinating officer to be consulted in case

ofneed.In case ofForeign Missions in India and other foreign agencies, the name and designation ofthe authorized officer along with details

of officials etc. for whom the connection is intended.In case ofogtstation subscribers, details oflocal reference(s) /Address be given at Column (1a) BillingAddress i LocalAddress to be

given.Paymentwillbe acceptedby cash/DD /pay orderin favorof 'oMTNLMumbaioDolphin'o forGSM service and"NITNLMumbai"

for any other service.For availing telephone under concessional category, requisite documentary proofhas to be submitted along with applicant. Contact

our customer care executive or Toll Free Helpline or website for more detail.Any WI-FI connectivity deployed by subscriber has to be activated only after it is registered to centralized authentication with

MTNL.For more details or any help visit our websitehttp:llmumbai.mtnl.net.in or Dial our Helpline

(a)

(b)

(c)

(d)

(e)

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(e)

(h)

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SPECIMEN SIGNATURE

(FOR CUSTOMER SERVTCE CENTRE)

a) Name of the Company / Firm / Applicant :

b) Consumer No.

c) Date of Registration

d) Telephone No.

e) Work Order No. & Date

(b,c,d & e for office use only)

f) Signature of Applicant(to be signed at the time of application

with Rubber Stamp)

SPECIMEN SIGNATURE(to be given to customer at the time of registration)

(To be given back to MTNL Staff at the time of lnstallation of phone)

a) Name of the Company / Firm / Applicantb) Consumer No.

c) Date of Registration

d) Telephone No.

e) Work Order No. & Date

(b,c,d & e for office use only)

f) Signature of Applicant(to be signed at the time of application

with Rubber Stamp)

l, Shri/Smt./Kum.

Resident of

an Employee / Partner / Director of (Name of the company if applicable)

is duly authorised to have the telephone installed at the above address on behalf of me / the

company /firm.

I affirm that the telephone is for bonafied use of the individual / company / firm.

Kwality Prints / 02-2011l Qty : 4,00,000 Nos. Signature with seal

FORM NO.60(See third proviso to rule 1148)

[Form of Declaration to be filled by a person who does not have either a Permanent Account Number orGeneral lndex Register number and who makes payment in cash in respect of transaction specified in clause(a)to(h)of rule 1148.1

1.Full Name and address of the declarant

3.Amount of the transaction

4.Are you assessed to tax ? : Yes / No

5.lf yes,(i)Details of Ward I Circle lRange where the last return of lncome was filled :

(ii)Reasons for not having Permanent Account Number/ General lndex Register Number:

6.Details of the documents being produced in support of address in column (1)

t,..........above is true to the best of my knowledge and belief.Verified today, the day of (Month), 201

Date:Place : ............. Signature of the declarant

lnstructions : Documents which can be produced in support of the address are :-(a) Ration Card(b) Passport(c) Driving Licence(d) ldentity Card lssued by any lnstitution(e) Copy of the electricity brill or telephone bill showing residential address(f) Any document or communication issued by any authority of Central Government,

State Government or local bodies showing residential address(g) Any other documentary evidence in support df the address given in the declaration.