BB Application Form

15. Choice of Tariff Plan:□ Startup Plan 250 □ Home 500□ Home 1000 □ Home 1800 □ Home 3300 □ Home UL 900 Plus □ Home UL 900□ Business 700 □ Business 1200 □ Business 3000 □ Business 5000 □ Business 900016. Do you wish BSNL to provide modem: □ Yes □ No(Fill in item 17, item 18, only if your answer for item 16 is Yes)17. Choose the Modem purchase option: □ Rental □ Purchase18. Choose the type of Modem: □ Type-I □ Type-II □ Type-III □ Type-IV19. Do you need a Static IP from BSNL: □ Yes □ No(If your answer for item 19 is yes, you will have to fill in a separate application for Static IP and submit along with thisform)20. Preferred Activation Date: _________________(dd/mm/yyyy)21. Choice of Data One access user-ids:(Note: The length of the user-id should not exceed 12 characters)1. _________________2. _________________3. _________________4. _________________22. Choice of Email ID:(Note: The length of the user-id should not exceed 12 characters)1. _________________@ bsnl.in2. _________________@ bsnl.in3. _________________@ bsnl.in4. _________________@ bsnl.in23. Choose the payment option: □ Monthly □ Annual24. Billing Address:(Note: Address to which you want BSNL to send the Invoices)Address Line 1 :Address Line 2 :Area :City :State :PINContact Phone with STD 0