Annexure E

Declaration for Outstation Customers

Date -

To,
M/s_____________(Mobile Services)

I ……………………………………………………Son/ Daughter/ Wife of

…………………………………….have applied for a ________Mobile Prepaid
/Postpaid Connection & do not possess any local residential address proof.
Therefore, I have furnished my Proof of Identity (POI) & Proof of
Address (POA) of my permanent address. In view of the same I hereby
confirm that I reside at the below given local address.

Subscriber Local Address details Local Referee’s Name & complete

address
Name; Name;

Address: Address:

Local Contact No.*

*in case of non-availability of contact number, proof of address of above reference is mandatory.

I understand that my mobile connection will be activated only after due

verification of the details furnished by me as above & in the Customer
Application Form (CAF) as well as in this declaration form.

Full Name of the Full Signature of the Date

Applicant/Subscriber Applicant/Subscriber

Mobile No. SIM NO.

Certificate of Compliance as per 3 (i) dated 22/11/06 (POS)

I / We hereby confirm that I / We have tele-verified the particulars

furnished by the subscriber with the local referee and record its
correctness.

Local Referee’s Name

Telephone contacted
Calling party’s No.(Pos)
Date of Calling : Time :

_________________
Seal & / Full Signature
of the Retailer (POS)

Certificate of Compliance as per 3 (ii) dated 22/11/06 (Dealer /

Distributor)

I / We hereby confirm that I / We have cross-verified that the Retailer

(POS) has tele-verified the local referee correctly & record its
correctness.

___________________
Seal & / Full Signature
of the Authorized
Representative of
Licensee (Dealer /
Distributor)