Affix self signed                             (http://www.calcuttatelephones.com)                                     FORM FOR NEW TELEPHONE CONNECTION           photograph (required for ISD facility only) Companies / Organisation Individual (Please tick the appropriate box)        1.A Title / Name of the Customer/Company/Firm/Organisation (SURNAME FIRST) B.Name of the Nominee [In case of Company/Firm/Organization name of authorised person] (SURNAME FIRST) C.Relationship with the applicant 2. Name of Father/Husband/Group/Proprietor/Partner(s)/Directors (SURNAME FIRST) 3. Date of Birth 4. Contact/Nearby telephone No./ (In case of individuals) d d m m y y y y Mobile No. 5.Complete Installation Address: C/o:    House No. Street/Road/Village     Bldg/Appt Flat no Block no Area/Locality/Tehsil       City/Dist PIN 6. Billing/Correspondence Address (if different from 5 above) 7. E-mail address (if any) : ____________________________________________@____________________ 8. Category code. (Please write code No. As indicated in 9. Consessional Group Code (Please write code No. As indicated     guidance no. 9)      in guidance no.10) 10. Purpose:     Residence Business Govt. PSU (Please see guidance No. 3,4,5,6) 11. Facilities required (tick whichever is required) (You may fill in more than one choice) (Please affix photograph for ISD facility): STD ISD CLI Hotline Conferencing Call forwarding Abberviated Dialling 12. Whether Telephone instrument is required Yes No (Please  see  guidance no. 2 ) If yes type of instrument (Please see guidance no. 13) Ordinary     Enhaced feature instrument with CLI 13. Whether Internal wiring is required    Yes No 14.  Do you want to keep your line unlisted Yes No (Please see guidance no.2) (Please see guidance No. 14) 15. Billing Services required (a)   Do you want to join ECS ? Yes No (b)   Do you want Bill bouquet service ? Yes No (Please see guidance No. 15) (Please see guidance No. 16) 16.Payment Details: Cash Cheque Demand Draft Amount in Rs. Cheque/Demand Draft No. Dated d d m m y y y y Drawn On : Bank Branch I hereby declare that information given above is true to the best of my knowledge and I will abide by the prevailing telegraph Act/ Rules framed In the event of any dispute concerning any telecom line, apparatus or appliance, bill etc, between me / us and BSNL, the matter will be referred to the sole Arbitrator, appointed by a nominated authority in BSNL and shall be governed by the provisions of the Arbitration and conciliation Act, 1996. Signatre of Customer/Authorised Signatory d d m m y y y y Signed on:        Date as amended from time to time. I am not a defaulter on account of non payment of bills for any telecom services provided by any service provider.        passport size BHARAT SANCHAR NIGAM LIMITED