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  • Application Form For Leased Line

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    somiya
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    The document is an application form for an internet leased line from BlazeNet. It requests information such as company name, contact details, address, bandwidth needed, payment details, and identity verification documents. The applicant declares the information is true and correct. BlazeNet staff sections are for internal use only such as approving the business and technical aspects, activation dates, and invoices.

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    Application+Form+for+Leased+Line

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    The document is an application form for an internet leased line from BlazeNet. It requests information such as company name, contact details, address, bandwidth needed, payment details, and identity verification documents. The applicant declares the information is true and correct. BlazeNet staff sections are for internal use only such as approving the business and technical aspects, activation dates, and invoices.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    17 views1 page

    Application Form For Leased Line

    Uploaded by

    somiya
    The document is an application form for an internet leased line from BlazeNet. It requests information such as company name, contact details, address, bandwidth needed, payment details, and identity verification documents. The applicant declares the information is true and correct. BlazeNet staff sections are for internal use only such as approving the business and technical aspects, activation dates, and invoices.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as RTF, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    BlazeNet

    Application Form for Internet Leased Line

    Internet Solutions Provider

    Company Name:

    403/404 Sarita Complex, B/h Hotel Classic Gold


    Off C. G. Road, Ahmedabad 380 009, Gujarat, India
    Phone: +91 79 2640 5996 / 7 Fax: 2640 5998

    ___________________________________________________________________________________

    Admin Contact Name: ________________________________________________Job Title:_____________________________


    Address 1:

    _________________________________________________________________________________________

    Address 2:

    _________________________________________________________________________________________

    City:

    ____________________________Pin Code:______________________State: Gujarat_________________________

    Admin Phone (O):____________________________________________________Admin Mobile:_________________________


    Admin Email:________________________________________________________Type of Customer:______________________
    Technical Contact Name:______________________________________________Job Title:_____________________________
    Technical Phone (O):_________________________________________________Technical Mobile:______________________
    Technical Email:________________________________________________________________________________________
    POP:________________________________________Bandwidth:_________________________________________________
    WAN IP Address:

    LAN IP Address:

    Transport Media:_______________________________Las t Mile Access Provider:____________________________________


    Annual Charges (Recurring):______________________________________________________________________________
    Installation Charges (One Time):___________________________________________________________________________
    Account Done By:_____________________________________________Payment Cycle (M / Q / H / Y):___________________
    Address Proof: Telephone bill / Electricity Bill / Ration Card / Statement of Bank or Pass Book / Statement of Credit Card
    Photo Proof:

    Passport / Driving License / Identity Card of Student / PAN Card / Voter Identity Card

    I / we / rep. of company declare that all the information related to our company on this form are true and correct to the best of my knowledge.

    Customers Signature with Stamp

    Place:

    Date:

    Account Accepted By (For BlazeNet use only)

    Business: ____________ Admin: __________________ Network: _________________ Accounts: _________


    PO Date: ____________ Login Date: ______________ Activation Date: __________ Invoice Date: _______

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