(CPMD /FLTE/021/V1.

1)

SRI LANKA TELECOM PLC

Registration No: PQ 7

(To be filled by SLT staff)

Account No CRNO.

APPLICATION FOR NEW CONNECTION - Service via LTE

1 General Information
1.1 Name in Full Rev.Mr/Ms . Other

1.2 Date of birth D D M M Y Y Y Y

1.3 Company name/ Partnership name/

Sole Proprietorship

1.4 Name of the partners (name with initials) 1

in case of partnership/name of the proprietor
in case of proprietorship (Attach copy of
Business Registration forms) 2

1 .5 National identity card/Passport/Business registration No.

(Attach copy of NlC/Passport/Business registration/Incorporation certificate as per Act No 07 of 2007)

1.6 Service installation address

1.7 Billing Address with Postal code

(if different from 1.6)

2 Contact details
2.1 Name
2.2 Designation
(for business customer only
2.3 Contact numbers Fixed Mobile
Fax E-mail address

3 Organizational Information (For Business)

3.1 Address of the principal place of business

3.2 VAT Registration number

3.3 If you are exempted from tax please

provide the exemption reference.
Instructions : Copies of Business registration certificate, FORM 20,documentary proof (if tax exempted) has to be submitted along with the
application.

4 Package Details
4.1 Package Type
a) Single Play (Broadband only) b) Double Play (Broadband with Voice) c) Other Specify ………………………………….
5 Preferred Broadband Package
A. Broadband Package Details:
5.1 Package Name: (Please mark "X" in a appropriate box)
a) Web Lite b) Web starter c) Web Pal d) Web Family Plus
e) Web family Extra f) Web Pro g) Web Master h) Web Champ
i) Web Life j) Web Inspire k) Web Premier l) Other …………………

User Name (i) (ii)

5.2 If Customer needs VMS, DNS, WEB Services and/or more than two e-mail accounts, SLT Net application has to be filled separately
(Applicable only for Web Master, & Above packages)
5.3 One Static IP with mail, web, DNS service is required Yes No
(Applicable only for Web Pro, & above packages at an additional charges)
B. Equipment details:
a) Type of equipment (i) Indoor (ii) Outdoor (iii) Dongle
C. Remarks
Details of special/promotional/ Commitment package or any
other.
6 Voice
6.1 Number of voice lines a) One b) Two
6.2 Preferred Price Plan a) Mega Home b) Mega Office
6.3 Other Services
6.4.1 If you need any other value added services/features, please mention(relevant rental charges applicable)
a) TeleLife b) Quick Meet c) Other ………………………………………………..

6.4.2 SLT IDD is enabled. If you wish to deactivate IDD facility please mark. a) Deactivate IDD (N.B - Mandatory to fill)

6.5 * Value added services (VAS) available

I. Double play VAS (Free of charge ) (Y/N)
II. Triple play VAS (With monthly rental) (Y/N)
VAS product catalogue can be obtained from SLT officer. * Subject to service availability.

Customer Agreement SLT Acknowledgement

I/We do hereby declare that the information furnished by me
/us are true and correct and agree to abide by the terms and
conditions for the received herewith which shall from in
an integral part of this Agreement which I/we have read
and understood and those which may be enforced in future
by SriLanka Telecom PLC (SLT)
SLT Acknowledges the offer by the Customer and shall
endure its best effort to provide the service, such
provisioning of the service shall construe the final
acceptance on the part of SLT and forthwith the
Agreement between SLT and the Customer shall come
in to force in which the "Terms & Conditions for the
provision of services via LTE by SLT shall form an
integral part.

Signature(s) 1. ……………………………………………………… Signature of SLT authorized officer ………………………………

Common seal 2. ……………………………………………………… Date ………………………………

Date …...……………………………………………

For Office Use Only Primary Number

CUSTOMER ID Secondary Number
Serial No : - -
ICCID/IMSI Number
Slit from here
Original copy
ACKNOWLEDGEMENT & ORDER ACCEPTANCE RECEIPT
Dear Valued Customer,
SLT hereby acknowledge your request with thanks. Please use the reference number seated below for future correspondence.
(To be filled by SLT officer)
CR Number 1 st Line
SLT Contact No. for 2nd Line
more information