Customer Agreement Form For New Land Line Telephone Connection

Company Name(s): 

(A Government of India Enterprise)
Advice Note/Work Order issued as per above filled entries
(Please use prescribed format)

Title/Name of the Customer/Company/Firm/Organization (SURNAME/FIRST NAME/MIDDLE NAME)
Tel. No. working, if any:

Call Forwarding

Signed on date
IT declaration in Form 60 / 61 as applicable
Conferencing Hunting Facility Abbreviated dialing
Broadband* *If yes, separate requisition for broadband may also be filled
(Please see instruction No. 3)
Category Code
Drawn on Bank
Whether Internal Wiring is required
Whether Nomination made
Facilities required:
Date of Opening
STD Code
Telephone Number Provided
Signature of Official with Designation/Official Stamp
Whether Tel. Instument is required
(Please see instruction No. 2)
Residence Business
Number of Telephone connections required
Complete Address where Telephone(s) is/are required
Companies/Organisation Nationality
Affix self signed
Concessional Group Code No.
(Please write category Code No. as indicated in instruction No. 10)
(Please write category Code No. as indicated in instruction No. 11)
E-mail ID
Date of Receipt of Form
Signature of Official with Designation/Office Stamp Indicator Number
Name of Father / Husband / Group / Proprietor / Partner(s)

Intial Payment
Certified that the identity, bonafide and address of the applicant have been verified by me / my representative
Name of Dealer/Point of Sale Signature
Signature of Customer / Authorised Signatory
Cash Cheque DD
Blocked Un-Blocked
(Pl. see instruction No. 9)
I/We hereby declare that information given above is true to the best of my/our knowledge and I/We bill abide by the prevailing Telegraf Act/Rules framed thereunder &
tarrifs as amended from time to time.I/We am/are not a defaulter on account of non-payment of bills for telecomservices provided by any service provider.I/We have
read and understood the terms and conditions provided overleaf i.r.o.Land Line Telephone services and with signing this form same shall be binding on me/us.I/We have
understood all rates,charges and related terms and conditions at which telecommunication services are provided by BSNL as applicable on this date and as amended
from time to time.I/We confirm that the information(s)/particulars supplied by me iscorrect in all respects.
Signed at place
The Category under which Tel. Connection is required to be registred in
Provider Customer Preference Register
Yes No
Signature of Official with Designation/Official Stamp
Billing / Correspondence Address if different from the place where Telephone(s) is/are required
(Please see instruction No. 12A)
Proof of Address enclosed (Please see instruction No. 12B)
In Words In figures
Cheque/DD No.
Credit/Debit card
Proof of Photo Identity enclosed
Tariff Plan Opted
Dealer Code and Stamp
Checked, Requisite documents are enclosed

In case of Government Departments, authorised person may sign and affix rubber stamp.

The form may be filled in Capital letters only.
If Customer requires more than one telephone in the same name & category at the same address, he/she may indicate here number of telephones required.
A rebate is admissible on the installation charges , if the telephone instrument and/or internal wiring is arranged by the subscriber.
In case of sole proprietary concern, proprietor may sign himself and affix rubber stamp.
In case of partnership concern, all partners or any one of the partners duly authorised or person with the power of attorney may sign and attach a copy of power of
attorney and partnership deed.
In case of company,signature should be of a person on behalf of the company in accordance with the provision of its Articles of Association and a copy of Articles of
Association may be attached.
For ISDN /BB Connections, the customer is required to fill up a separate form.
Blocked - If unsolicited commercial communications are not desired to be received on telephone.
Un-Blocked - If unsolicited commercial communications are desired to be received on telephone.
Concessional Group Code Freedom Fighters/SWS Gallantry Award Winners/Awardees of
President's Police Medal for Gallantry
War Widows/Disabled
Blind Persons Sr. Citizens
Non-Residential telephone connection in schools,Univeristies & collages affiliated thereto, Polytechnices, Non-commercial Reseach Organisations /
Homes for aged, infrim spactics, handicapped , deaf-dum-mute persons/ orphanages/ voluntary organisation for trible welfare & other like
institutions/organisations recognised by Government.
Documents required to be submitted as proof of Identity/Address:-
For proof of photo identity for individual customer (all identity proof to have photo of applicant), the customer shall submit any one of the following :
(a) passport, Arms Licence, Driving Licnse,Election Commission ID Card, Ration Card with photo (for the person whose photo is affixed), CGHS/ECHS card ,
Certificate of Address having photo issued by MP/MLA/Group A Gazetted Officer in letter head, Certificate of address having photo from Govt. recognised
educational institutions (for student), Certificate of photo identity issued by head of Village Panchyat or its equivalent authority (for rural areas). Income Tax PAN
card, Photo Credit card, Address Card with photo issued by Deptt. of Posts GOI, Smart card issued by CSD/ Defence/Paramilitary, Current passbook( with photo) of
Post Office / scheduled bank, Photo Identity Card (of Central Govt/PSU or State Govt/PSU only) Photo Identity Card issued by Govt. recognised institutions (for
students only) Cast and Domicile certificate with photo issued by the concernedState Govt , Pensioner Card having photo, Freedom Fighter Card having photo and
Kissan pass book having photo.
b) Public Limited Company applying for telephone connection may enclose certificate of incorporation alongwith any proof of Identity as above of the authorised
officer of company
( c ) In case of Government of India undertakings, Govt of India Offices/State Govt Offices, the above said requirement are dispensed with and self cetification on
the letter head will suffice along with the name and designation of the co-ordinating officer to be consulted in case of need
(d) In case of Foreign Mission in India and other Foreign Agencies, the name & designation of the authorised officer along with details of officials etc. are required
for whom the telephone connection is intended.
For proof of Address, the customer shall submit any one of passport, Arms Licence, Driving Licnse,Election Commission ID Card, Ration Card with address,
CGHS/ECHS card , Certificate of Address having photo issued by MP/MLA/Group A Gazetted Officer in letter head, Certificate of address having photo from Govt.
recognised educational institutions (for student only), Certificate of address issued by head of Village Panchyat or its equivalent authority (for rural areas). Water
Bill, telephone Bill of Fixed line (not older than last three months), Electricity Bill (not older than last three months), Income Tax assessment order, Vehicle
Registration Certificate, registered Sale/ Lease Agreement, Address Card with photo issued by Deptt of Posts, GOI, , Current passbook with photo of Post Office /
scheduled bank, photo identity card having address (of Central Govt/PSU or State Govt/PSU only) Credit Card Statement (not older than last three months), Cast
and Domicile certificate with address & photo issued by the concernd State Govt , Pensioner Card with address, Freedom Fighter Card with address and Kissan pass
book with address.
Foreign Nationals are required to enclose the copy of Passport.
Description of categories and documents required to be submitted by the applicant
Category Entitled Persons / Organization Documents to be attached (Duly self attested)
Doctors/Nurses/Midwives Recognized Degree/Diploma, Registration Certificate.
Press Accreditation Certificate form PIB
Advocate & Judicial Officers Regn. By Bar Council [for advocates]
Eminent Persons Proof of Recognition at State/National Level in any field.
Senior Citizens (aged 65+) Proof of age.
Gallantry Award Winners Copy of Award Letter.
War Widows/Disabled Soliers Documentary Evidence, Copy of PPO[for War Widows]
Blind Persons Visually Blind Certificate from CMO
News Papers Registration with the Registrar of News Paper
Small Scale Industries SSI Registration Certificate
Other Eligible Categories Documentary Proof.
N-OYT-SWS Freedom Fighters/Swatantrata Senani Copy of PPO & I-Card
N-OYT-SS MPs/MLAs/ Municipal Councilors/Presidents, Vice -Presidents,
Chairman of Standing Committee of Distt., Block and Gram
Panchayats and Members of Zila Parishads, Foreign Missions and
Embassies/UN Organisation
Subject to fulfilment of pay conditions and submission of documentary
N-OYT-G-SE-DoT Serving DoT employees Service Certificate, Service Book Entry Proof
Applicable registration fee
Telephone Category
Registration fee subject to revision by BSNL
Areas where telephone is available on demand Areas where telephone is not immediately available
on demand
All (Refer charges for concessional categories) Nil Rs. 500/-
Additional Applicable Security Deposit in case of Foreign nationals:-Foreign nationals have to make a security deposite of Rs.5000/- for NSD/Local and Rs.10,000/- for
ISD call facility. The security deposit could also be made in the form of hard currency of equivalent value. The amount of security deposite can be enhanced by
AO(TR) depending upon the usage of the telephone
In case of payment by Cheque, the same should be made in favour of AO (Cash), BSNL of concerned SSA. 17 APPLICABLE CHARGES FOR CONCESSIONAL GROUPS
S No. Concessional Group Registration
Rental Charges Installation Charges Remarks
i Freedom Fighters(SWS) NIL 50% of normal
NIL same concession applicable to widows of Freedom Fighters
Gallantry Award
Winners/Awardees for
President's Police Medal for
iii War Widows/Disabled Soliders NIL 50% of normal
rentals NIL
iv Blind Persons Full Charges 50% of normal
Full charges 50% of Annual Advance Rental
v Sr. Citizens NIL Full rentals Full charges Transferabled in the name of spouse after death in General Category
Non-Residential telephone
connection in
schools,Univeristies & collages
affiliated thereto, Polytechnics,
Non-commercial Reseach
Organisations/ Homes for
aged, infirm spactics,
handicapped, deaf-dum-mute
persons/ Orphanages/
voluntary organisation for tribal
welfare & other like
recognised by Government.
Full charges 75% of normal
rentals Full charges Concession applicable on maximum 2 connections
vii Retired DoT employees NIL NIL Full charges where actual
installation is involved
Free calls (Bi-monthly) In addition to free calls available to normal customer
Group-A 1000
Group-B 500
Group-C 300
Group-D 200
viii Retired BSNL Employees NIL NIL NIL
Free calls (Monthly) In addition to free calls available to normal customer
Executives falling in category E-3 and above including full time
director & CMD 500
Executive falling in category E-1 and E-2 250
Non Executives falling in category NE-5 to NE-11 150
Non Executives falling in category NE-1 to NE-4 100
ix Serving DoT employees NIL NIL NIl Free calls as admissible to normal subscribers
Non Executive employees in IDA pay scale of Rs.4250-6200 and
onwards (pre-revised) 100
Non Executive employees in IDA pay scale of Rs.4550-6650 and
onwards (pre-revised) 150
NOMINATION FORM [For Individual Applicant]
I hereby nominate the person mentioned below who shall, in the event of my death, be entitled to get the telephone/registration transferred through this
form/transferred to his/her name or be entitled to be paid the amount of registration/security deposit for the telephone so registred in my name, to the exclusion of all
other persons.
1. Name of the Nominee (In block letters)...............................................................
x Serving BSNL employees
NIL NIL NIL Free calls in addition to free calls admissible to normal subscribers
2. Relationship with applicant................................................................................
3. Full Address of the Nominee (In block letters)............................................................
4. In case nominee is minor, indicate the date of birh.....................................................
Signature of nominee Signature of Applicant
Name Name
Full Address Full Address
1. Signature of Witness......... 2. Signature of Witness..................
Name................. Name................
Address.................... Address................
IT FORM 60 of ITR, 1962 [To be filled by customer who does not have PAN & GIR No. and who makes payment in cash i.r.o transactions
specified in clauses (a) to (h) of Rule 114B. ]
1. Full name and address of declarant:
2. Particulars of transaction:
3. Amount of transaction:
4. Are you assessed to tax? Yes/No
5. If Yes,
(i) Details of Ward/Circle/Range where the last return of Income was filed?
(ii) Reasons for not having Permanent Account Number/General Index Register Number?
6. Details of the document being produced in support of address in Column (1)
Place....................................................... Signature of the declarant
I, hereby declare that what is stated above is true to the best of my knowledge and belief
Verified today, the of ..................(Month),20........................
Place....................................................... Signature of declarent.................................................
I, hereby declare that what is stated above is true to the best of my knowledge and belief
Verified today, the of ..................(Month),20........................
Place....................................................... Signature of declarent.................................................
IT FORM 61 of ITR, 1962 [To be filled by customer who has agricultural income and is not in receipt of any other income chargeable to income
tax i.r.o transactions specified in clauses (a) to (h) of Rule 114B. ]
Particulars of transaction:
Details of the document being produced in support of address in Coulmn (1) Yes/No
I hereby declare that my source of income is from agriculture and I am not required to pay income tax on any other income if any
Date.......................... BSNLshall be at liberty to provide the services under any brand name.
Applicants/Customers are requested to read the following terms and conditions before signing the application for new telephone services:
"Customer" Means a person/company/firm /or any other association of persons who has subscribed for services under this agreement.This agreement binds
the customer and whenever &wherever applicable, his heirs ,executers,administrators,successors and permitted assigns and benefits BSNL and its successors
and assigns.
"Services" Means the services, which enables the customer when using the telephone equipment to have two-way communication over the network and
includes other value added/supplementary Services offered by BSNL and specifically,opted by the customer.
"Tarrif" Means and includes the agreed Tarrif schedule and all rate and related conditions such as deposits, installation fee,usage charges and any
other related fees and service charges under the Tarrif schedule as notified and published by BSNL from time to time for providing the services and value
added/supplementary services.
1.1 The customer shall ensure that He/She will duly fill and sign the prescribed form for New Land Line Telephone Connection and all other required forms, besides
furnishing other particulars/documents for identification as required by BSNL/Govt. of India from time to time to become elgible for subscribing to the said
services rendered by BSNL. In the event of any default, on the part of customer, BSNL shall have right to refuse the connection without any liability and without
assigning any reason. .
1.2 Subject to the acceptance of the application and technical feasibility, BSNL will endeavour to provide the telephone service as soon as possible.
1.3 For change/addition/deletion of any features/supplementary services/schemes/plans, customer shall fill up the requisite form and be bound by all the terms
thereof. Any change or withdrawl of any supplementary services etc shall not entitle the customer to any refunds or adjustments for the money already paid, or
to be billed under additional terms.
1.4 The customer shall fully abide & comply the provisions of Indian Telegraph Act, 1885 and the Indian Telegraph Rules, 1951 and rules made thereunder and as
amendments or replacements made thereto from time to time.
1.5 Where two or more persons constitute the Customer, their liability shall be joint and several.
1.6 Any notice required to be given by the Customer to BSNL shall be given in writing to the BSNL at the designated address.
1.7 Scope of the services is governed by the Statutory Guidelines issued by the Telecom Regulatory Authority & Govt. of India within the parameters of License
Agreement executed with Ministry of Communications, Govt. of India.
1.8 Customer represents that he has been fully informed & have fully understand about the Land Line Telephone Services provided by BSNL, its specifications,
requirements, limitations, tariff etc. and has only thereupon signed the aggreement
1.9 In case of permanent disconnection of telephone, number may be alloted to another customer as per the sole direction of BSNL. In that event, the customer shall
not have any right or lien on the number. In case of suspension /disconnection etc. reconciliation may be made by BSNL in its sole discretion on such additional
terms as BSNL may determine.
1.1 0 All charges and other sums due to the customer shall be paid by prescribed due date failing which surcharge as deemed appropriate shall be charged by BSNL. All
charges must be paid in full without any deduction, set-off, withholding. All payments must be made in favour of AO (Cash), BSNL in concerned area.
1.1 1
1. 1 2 The information provided by customer/gathered by BSNL, shall become BSNL's property even if application is rejected/refused or connection is disconnected as
the case may be and can be used by BSNLin any manner,if deemed fit.
1.1 3 BSNL will not be liable for any dealings of the Customer with any party, which is not authorised by BSNL to deal on its behalf.
1.1 4 BSNL is not responsible for the Franchisees/Business Associates/Distributors/Channel Partners/Dealers /Retailers with regard to schems which are not authorised
by BSNL or which purporated to have been offered on behalf of BSNL without the latter's sanction.
2.1 BSNL will use its commercially reasonable best efforts to provide service to the customer. The customer agrees that, to maintain or improve service, or for other
business reasons, BSNL may at its sole discretion modify or temporarily restrict or suspend all or part of the services without notice. The Customer acknowledges
that the services are subject to transmission limitations caused by atmospheric or topographical conditins or equipment failures beyond the reasonable control of
BSNL. Services may be temporarily refused, interrupted or curtailed due to government's regulations or orders, system capacity limitation or equipment
modification, upgradation, relocation, repair, maintenance and similar activities necessary for the proper operations of the services.
3.1 If at any stage information furnished by the applicant in the application form is found false, telephone service is liable to be disconnected immediately without
3.2 BSNL reserves the right to terminate the services in the event of non-payment of bills issued by BSNL in accordance with the tariff plans opted by the customer
and the extent of usage or any default on the part of customer.
3.3 The customer shall be the sole responsible for using the service only for Lawful and appropriate purposes.
3.4 Customer shall not use the service provided by BSNL for any unlawful or illegal purposes of immoral, improper or abusive purpose or for sending obscene,
indecent, threatening, harassing, unsolicited messages, or messages affecting / infringing national interest nor create any damage or risk to BSNL or its network
and / or other matters. BSNL reserves the right to diconnect service, without liability, if any, at its sole discretion on any such event.
3.5 BSNL reserves the right to terminate the service to any customer in case there is sufficient evidence of the customer intentionally or unintentionally using the
service in the manner which would adversely impact BSNL or BSNL's Network.
4.1 BSNL will exercise all reasonable care in providing the services, but it is not responsible for interruption in service due to power failures, equipment malfuntions
or acts of natural calamity or any other reasons beyond its control.
4.2 BSNL shall not be responsible for actions taken by customers or others as a result of usage the services.
4.3 BSNL will not be liable to the Customer for any loss of business, profit, revenue or goodwill, anticipated savings, use or contracts or for any indirect or
consequential loss how so ever it arises.
5.1 The Customer agrees to pay to BSNL the subscription charges, call charges, opted value added service charges, supplementary service charges, BSNL charges for
calls made from fixed network to other network, monthly rental, NSD/ISD charges, service tax, other taxes & duties etc. and other charges payable for the
services as published and notified by BSNL as per tariff applicable from time to time.
5.2 The rate of deposits, connection charges, fixed monthly charges, call charges and other payable charges are set out in the "Tariff Schedule" as notified by BSNL.
BSNL shall have the option to vary the tariff, charges for value added services, supplementary services and any other conditions of services, retrospectively or
prospectively and the same shall be binding on the customer.
5.3 The billing cycle shall normally run on monthly basis or such other frequency as may be decided by BSNL from time to time and the periodic bills shall be issued
accordingly. The customer is responsible to pay his bills by the prescribed date. It is incumbent on the customer to enquire his/her balance and settle the same
even in case of non-receipt of monthly bill for any reason whatsoever.
5.4 BSNL reserves the right to raise interim bills and customer agrees to make such interim payment as and when required by BSNL based on internal credit rating of
the customer by BSNL.
5.5 Bills will be sent to the billing address of the customer as furnished by him/her. For any change of address the billing department should receive notification in
writing well in advance to change the address along with proof of new address to accept the change.
5.6 Where a sercurity deposit has been paid, BSNL is entitled to retain it and apply it as it decides in full or parital satisfaction of any sums due from the customer to
BSNL any time. No interest will be paid on deposit.
5.7 The payment against monthly bills beyond the stipulated date shall entail a charge @ rate/fixed amount as may be decided by BSNL from time to time, over &
above the payment from the date it became due. This however is without prejudice to the right of BSNL to suspend the services partially or fully due to non-
5.8 The call pulse rate be governed by the rules and regulations as specified by the Regulatory Authorities from time to time and/or specifically specified by BSNL.
5.9 The itemized monthly bills are available on request and are chargeable in nature at such rate as may be decided by BSNL from time to time
5.1 0 BSNL is entitled to change, vary, add and withdraw any services/supplementary sevices/schemes/plans etc.and/or vary the terms and charges at any time at its
sole discretion. The rates/charges may also change as per the directions of TRAI or any statutory authority from time to time.
6.1 Privacy of communication or contents of information using services is not guaranteed and is subject to Government's regulations and other such factors viz
Communication content/information is subject of Legal or administrative demand orRules or Regulations of Govt. or appropriate authority.
7.1 In the event of any dispute, the matter will be referred to the sole Arbitrator appointed by the nominated authority in BSNL and will be governed by the provisions
of the Arbitration and Conciliation Act, 1996 or any statutory modification or enactment there-of or any rules made there-of.Customer will have no objection in
any such appointment that arbitratior so appointed, is employee of the BSNL.
7.2 This agreement shall be subject to the jurisdiction of appropriate courts according to location of office of Chief General Manager Telecom,BSNL of the area
concerned & laws of India
Place........................................ Date.................................. Signature of Customer/Authorised Signatory...........................................................................