NEPAL TELECOM N

NEPAL TELECOM
(Nepal Doorsanchar Company Limited)
APPLICATION FORM
Broadband Wireless Service ( [ ] WiMAX [ ] Wifi )
passport size
photograph with
Customer
authorised
signature
1. Customer’s Name (in BLOCK LETTERS):
2. Customer’s Permanent Address:
Ward No House No Street Name Tole Name
Zone District VDC/Municipality
3. Installation Address:
Ward No House No Street Name Tole Name
Zone District VDC/Municipality
4. Customer’s Mobile: Email:
5. Customer’s Identity: Citizenship Passport PAN Others
specify
Number:
District:
6. Name of Company/Firm/Organization:
7. Company/Firm/Organization’s Full Address:
8. Customer’s ID:
9. Type of CPE required: Outdoor Indoor USB Dongle
10. Packages: 256 Kbps 512 Kbps 1Mbps or above
11. Type of User: Single Multiple
12. Purpose: Residence Business Government
N
Site Map of the user’s premises from the Main Road ……………………………....
Distance of residence is ….......………. meters from nearest Main Road.
Finger Prints
right
left
.......................................
Customer’ Signature
Date : 20 / /

FOR OFFICE USE ONLY
A Application Received Date
B CPE Make
Receipt No
Model
C MAC CPE
D Date of activation
E Vendor ................................................
Signature
Name
Designation
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