FORM

(See regulation 11 of the of Telecom Consumers Protectionand Redressal

of Grievances Regulations, 2007}
Appeal under regulation 11 of the Telecom Consumers Protectionand
Redressal of Grievances Regulations, 2007 to the appellate authority
appointed byTata Communications Internet Services Limited (TCISL)
Head Office - Tata Teleservices Limited. A&E Blocks, Voltas Premises, T. B. Kadam Marg,
Chinchpokli, Mm!ai " #$$ $%%
Regd. Office Tata Commnications &nternet 'ervices Limited, ()# Capt *ar Marg, 'rinivaspri,
+e, -elhi ..$ $/0. ..
1. The Name, Address, Telephone Number,
Facsimile number and the e-mail address of
the Appellant.
2. Telephone Number or Cellular Mobile
Telephone Number or Broadband
Connection Identit, as the case ma be, for
!hich appeal is filed
". The name of the cit #district of the ori$in of
complaint
%. The name of the &tate or licensed ser'ice
area, as the case ma be, of the ori$in of
complaint.
(. Nature of Complaint )specif, !hether
complaint relates to
*ro'isionin$#Acti'ation#Billin$# Fault-
+epair#&er'ice disruption #disconnection of
ser'ice# ,alue Added &er'ice # Closure #
Termination or specif if an other-.
.. The doc/et number allotted b the Call
Centre at the time of lod$in$ complaint
under clause )a- of sub-re$ulation )1- of
re$ulation % and date of lod$in$ the
complaint !ith the Call Centre.
0.The uni1ue complaint number
communicated b the Nodal 2fficer under
clause )c- of re$ulation 3, and date of lod$in$ the
complaint !ith the Nodal 2fficer.
3. 4ate of decision of the Nodal 2fficer and
decision intimated b the Nodal 2fficer

under clause )d- of re$ulation 3, if an.
5. &tatement of Facts relatin$ to $rie'ance or
appeal6 )attach separate sheet si$ned b
Appellant if re1uired-
17. 8rounds of Appeal6
A full description of the matter, !hich is the
cause of the $rie'ance, includin$ copies of an
rele'ant and supportin$ documents,if an, and
the relief claimed in Appeal )attach separate sheet
si$ned b Appellant if re1uired-.
11. A statement to the effect that same
sub9ect matter or issue, for !hich an appeal has
been filed under these re$ulations, is not
co'ered in an proceedin$s before an court or
tribunal or under the Consumer *rotection
Act,153. ).3 of 153.- or an other la! for the
time bein$ in force.
12. 4etails of an other rele'ant material or
document.
1". :hether the Appellant
re1uests to $rant him e;emption
from appearin$ in person and
decide the appeal on the basis of
information, document or record
filed b him.
Form for verifcation
I,_______________________________________(name in full and in blockletters),theappellant,
son/daughter of _____________________________ do hereby declare that to the best of my
knowledge and belief, the information given in this appeal and the annexure and
statements accompanying the appeal are correct, complete and truly stated.
<<<<<<<<<
Signature of appellant
(Name of appellant)
(Specify status of the appellant, whether a company/frm/society/ individual/
others ....)
Note1. The Form of appeal, grounds of appeal and the Form of verifcation appended shall be signed by the appellant.
Note2. The appellant shall submit in duplicate the appeal in this Form.