BHARAT SANCHAR NIGAM LIMITED
(www.aptelecom.gov.in)
FORM FOR TEMPORARY  TELEPHONE CONNECTION
Affix self signed passport size photograph
(required for ISDfacility only)
Companies/ Organization 
( Please tick the appropriate box)
 

Individuals
 
( Please read the instruction before filling the form )
1. A Title/Name of the Customer/Company/Firm/Organization ( SURNAME FIRST)
                                                                     
B. Name of the Joint Applicant, if any
                                                                     
2. Name of Father/husband/Group/Proprietor/Partner(s)
                                                                     
                                                                     
3.PAN/GIR No.
                   

4.Tel No.working,if any
             
( please see Instruction #2)
5. Complete Postal Address

House No

             

Street/Road/Village
                             

Bldg/ Appt
                                                             

Area/Locality/Tehsil
                                                             

City/District
                           

PIN
           
6. Billing/ Correspondence Address ( if different from 5 above)
                                                                     
                                                                     
7. Period for which connection required : from___________to_________     8.Purpose_______________________
9.Status of Applicant :

Individual
 

Firm/Company

 

Government/PSU
 
10.Grounds on which temporary Telephone is required
(for Medical grounds,Medical Certificate issued by Registered Medical Practitioner to be attached)
11. Facilities required ( tick whichever is required) ( please affix photograph for ISD facility):

            STD
 

ISD
 

CLI
 

Hotline

 

Conferencing
 

Callfarwarding

 

Abbreviated Dialing
 

12.Whether Telephone instrument is required(Y/N)
 
 13. Whether Internal Wiring is required  (Y/N)
 

14.Payment Mode : Cash
 

Demand Draft
 

Amount
               

     Payment Details: DDNo.
           

Dated
               

     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 thereunder & Tariffs as amended from time to time. I am not a defaulter on account of on-payment of bills for any telecom services provided by any service provider.


Signature of  Customer/Authorised Signatory


Signature of  Customer/Authorised Signatory

Signed on :         Date