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11. HusbandMife' s Name.(lf. married): (ln
12. Second Contaet- Name & Address: (ln
t -
13. Mobi l e / Tel No:
- - - - - - - : - - r - . i - - \ - - - - - - -
14. Land phone numbers under hi s/ her possessi on: ---------: . --
----
15. Photo ldentity document:
(National lD Card/Driving License/Gun License/PassporVBTRC-2006 (A)/Other ldentity Document with Photo)
Operator's Representative/Authorized Seller
I have personally verified the auched photograph
and i denti fy of the appl i cant.
Si gn wi t h Seal :
- - - - - - - - - r . - - -
Name and Address:
. i .
\
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J
Date: : ,
t l
lssued Customer lD:
1. UsitrlhdividuafContpany' s Name:
[_l
Pre-paid
!
Post -pai d
( l n Bengal i ) - - - - -
( l n Engl i sh)
- - - - -
2.
.User'
Name (ln case of company) (ln Bengali)-
Bengal i ) - - - - - - - - - ( l n Engl i sh)
Nd: ' ire appticant must complete all sedes o' this fom and incomplete from is unaccepbble'
ve*nted in front ofthe selter and atteste lhotorcpy of the same to be submited
3. in se ofasterisk (.) marks, informatir garding Bangladeshi citizens to be given both in Bengali arc =- sr
Please preserue this Copy for future
Office use only
l nstal l ati on address:
Billing Area:n DhafaICnittagong L
sytnetI Khulna/Others
category:
!
tndiviouat l-lBusiness !Corporate
Package:
!
Post Paid
!
Pre-Paid
Package Detail:n 256Kbps
!
stzrups
[
1 Mbps
[]
2Mbps
Preferred E-mail lD:1.
Usage Al l owance: Sky/-
- -- - - - - - - -
Wi MAX Modem Number:
MAC ( OFDM) r D
Qubee A C Nrl mber:
Tk. |
1' ' r i l Cash payment Made
16718t38
f
ackese-3erljls
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I C e
Package name
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i l
Modem
I
Bandwi dth Fee
l l ' Instal l ati on Fees
i l
Secuti ty Deposi t (l f)
i l Tax&VAT
il
Total: Tk.
A'
il credit""dno,l-T-l-f-l l-l=[[l fTTl-l rr[[l
Saf es Per son Si gnat ur e: - - - - - - . - - - - - - '
Sal es Per son Name: - - - - - - - - - - -
Sal es l D:
- - - - - - . -
o
o
E
O
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",
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Tk.
Tk.
Dat e: - - - - - - - - - - - -
,'n
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Customer Si gnature: i
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Augere Wi rel ess Broadband Bangl adesh Li mi ted
Corporate Offi ce:Mostafa Center, Road 27. Pl ot 59, Banani , Dhaka-1213, Tel :+88 028812113, Fax:+88 02 8812115