NEPAL TELECOM

passport size
photograph with
Customer
authorised
signature

(Nepal Doorsanchar Company Limited)

APPLICATION FORM
Broadband Wireless Service ( [ ] WiMAX [ ] Wifi )
1.

Customers Name (in BLOCK LETTERS):

2.

Customers Permanent Address:

Ward No

Zone

District

Installation Address:
Ward No
House No

Street Name

Zone

District

3.

House No

Street Name

4.

Customers Mobile:

5.

Customers Identity:

Citizenship

Number:

Passport

Tole Name

VDC/Municipality

Tole Name

VDC/Municipality

Email:
PAN

specify

Others

District:

6.

Name of Company/Firm/Organization:

7.

Company/Firm/Organizations Full Address:

8.

Customers 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

Site Map of the users premises from the Main Road ....

Government

Finger Prints

Distance of residence is ........ meters from nearest Main Road.

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
................................................
Signature
Name
Designation

E Vendor

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