*1.

Type
of service required
Please tick (/;
MAHANAGAR TELEPHONE NIGAM LTD
Jeevan 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;l
Father'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/arriedl
c) 20,000-3O,OO0
f]
10.
n
n
*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 -50,000
b) 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:
tl
tl
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 Guide
At 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 inMTNlbrochure
At 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/Video
on Demand / Fixed IP addresses / Call forwarding /Abbreviated dialing / CLIP / any other. The details of value addecl addresses are
giveninMTNlbrochure
At 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 / GovernmentAuthority
Public 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)
(0
(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 / 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)
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 or
General 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.