BHARAT SANCHAR NIGAM LIMITED

(A Govt. of India Enterprise)

REQUEST FORM FOR BROADBAND SERVICE

Telephone No:_____________________________ Mob No : _______________________

Name: ___________________________________
Email Id : _______________________
Address: _________________________________
_______________________________
_________________________________________
(1) Change of Plan: Monthly Annual Bi- Annual Tri-Annual
(11 Months) (21 Months) (30 Months)
Existing Plan to New Plan

(2) Change of Modem :

- Purchase from BSNL Type – I Type – II VDSL

- Rented from BSNL
- Rented to Purchase/Owned

(3) Disconnect or Provide

o Static IP (chargeable)
o LKLB (lo kar lo bat)
o Add no 48 (Gujarat) Add on 98 (India)

o Other: _________________________________________________

For Office Use Only:

Request No._____________________ Signature of Customer

With Stamp
Order No._______________________
Date: ___________ Sign: Franchise code : C000701108
Remarks: _______________________ Employee Name:__________________