Leased Line Internet Application Form - BTCL

Bangladesh Telecommunications Company LimitedRegistrant Name :Name and designation of :authorized personAddress :City and Post Code :Email Address :Phone and Fax Numbers :LEASED INTERNET ACCESS APPLICATION FORMREGISTRANT INFORMATIONRegistrant Category : Educational Government Industrial ISPInternational Org. Foreign Org. Others.Connection Type : Permanent Temporary Others.Initial Commitment Period : Month (s) Year (s)[A] Billing ContactFull Name :Title/Occupation :Organisation (if applicable) :Address :City and Post Code :Email Address :Phone and Fax Numbers :[B] Technical ContactFull Name :Title/Occupation :Organisation (if applicable) :Address :City and Post Code :Email Address :Phone and Fax Numbers :CONTACT INFORMATIONPage 1 of 2

[A] General InformationTECHNICAL INFORMATIONDesired Bandwidth (always symmetric) : Kbps/ MbpsExact address of the Connection :Local loop will be provided by: BTCL: Customer (Optical Fiber/ Others................)Terminating equipment at the subscriber end : Router Switch DCE/ModemModel of Terminating Equipment :Interface of Terminating Equipment : GBIC GE SFP FE Other[B] IP Related InformationIP Address Need for Host[BTCL will not provide IP addresses with thisbandwidth. IP addresses may be procuredseparately from BTCL]IP Route AnnouncementWe don’t need IP addresses from BTCL. We’ll useour own. [Please describe the IP blocks to be forwarded]……………………………...........................................................................…We have our own IP addresses but need more............................................ IP addresses (Please apply in theprescribed application form) from BTCL.We don’t have IP addresses of our own. We need……………………………IP addresses. (Please apply in theprescribed application form)Default Route (You should add the default route toyour router; there is no need to run any routing protocol)BGP (If this option is selected, please use letterheadpad to provide BGP related information)Signature of the authorized person of the Customer:_______________________ Date:____________Registration InformationRegistration Number :Date :FOR BTCL USE ONLYSignature:___________________________________ Date:_________________________Circuit designation :IP addresses allocated :Date of service start :Signature:___________________________________ Date:_________________________Page 2 of 2