Video Conferencing Application Form

Please fill in the following information to avail Video Conferencing service

(Fields marked with * are mandatory fields)

 

 

Subscriber Details

* Title

Mr/Mrs/Miss

* First Name

 

Middle Name

 

Last Name

 

*Billing Address

 

*City

 

*State

 

*Country

 

* Pin Code

 

*Existing BSNL No.

 

Residence No.

 

Office No.

 

Mobile No.

 

Email Address

 

I have gone through the terms and conditions and abide by the same. *(Yes / No)

-------For Official Use Only-------

------To be filled by Customer Service Center-------

Received (Rs)

 

By (Tick one)

Cash/Check/DD

Cheque/DD No

 

Dated

 

Drawee Bank

 

Circle

 

Town/City/SSA

 

Received Date

 

Received By

 

------To be filled by Commercial Section------------

Status of the Application (Tick one)

Accepted/Rejected

If Accepted, Transaction No.

 

If Rejected, Reason for rejection

 

Date

 

Updated By

 

-------Subscriber’s Copy--------

Received (Rs)

 

By (Tick one)

Cash/Check/DD

Cheque/DD No

 

Dated

 

Drawee Bank

 

Circle

 

Town/City/SSA

 

Received Date

 

Received By

 

                     

 

 

Date:   ___/___/______ (DD/MM/YYYY)                                                        Signature: ___________________________

 

Place: ___________________________

 

Note: To view terms and conditions turn overleaf.          

Terms and Conditions

 

GENERAL:

OTHERS:

RIGHT TO TERMINATE SERVICES:

DISCLAIMER: