BHARAT SANCHAR NIGAM LIMITED FORM FOR FIBER BASED SERVICES NEW CONNECTION esepurtee photograph (cequired for Companios/ Organizations [] Individuals] FTTH facity ony) (tick appropriate box) (Please read the instructions before filing the form) Whether Existing CustomerofBSNL []¥es [[]No _ itYesprovide the Account Number 1. A. Title! Name ofthe Gustomer/(SURNAME FIRST) ‘Company /Fiem / Organization B. Name ofthe JointApplicant,ifany 2. NameofFather/ Husband! Group Proprietor /Partner(s): 3. Nominee Name: 4.PANIGIRNo: 5. Contact Numberifany: Home: Business Mobile 6. Complete Addross whore sorvica(s) is/are required: House No. Street/ Road /Vilage Bldg /Apot. ‘Area Localty Tehsil city/oistriet PIN, State 7. Billing! Correspondence Address (itatfernt fom 6 above) House No. Stroet/ Road! Vilage dg /Appt. ‘Aroa/Locaity/Tehs City Distiet PIN, State 8. E-malladdress (fany) @ 8. Gender: []Male [] Female 10, Dateot Birth ‘11. Whetherthe applicantisaretired orworkingEmployee ofGovtspsurcpsu! [Yes [JNo 12. Purpose: [residence [[] Business [oou. Cesu 13. Service Type: [sroadsans FJ iPtvicastetv [Telephone [] vineo 14. Numberof Connections Required []Broadbané FJ PTV Li tetephone 16a. Facilities Required on Telephones tick whicheveris required) (please affxphotographforISD facity) sto] tsoL] cui] Hotine[] conferencing[] CatfForwarsing[_] Hunting acity ["] Anbreviated dating [—] 4150. Facilies Required on Video (lick whichever is required) (please affx photograph for ISD facilly Videoconferencing[] -VideoCals[_] others] 416. WhetherTelephone instumentis required: []¥es []No 417. WhetherSTBis required: []¥es []No 18. Typeotont: []typeA — L]type8 49a, Mentionthe tarifpackage required for Broadband Pry Telephone [Please see various tarifpackages available] 490. Billfrequency 1 Montiy EJ yearty — ] Five Yearly 419c. Bundled Service Packages 20, PaymentMode: Cash/Demand att ‘Amount PaymentDetails: ODNo, Dated Drawn On Bank Branch Urey dere that nfomaton given aoveis tue athe best of my knowledge and! wil abide byte prevaling Telgaph Act Rules ames thereunder & Tis ‘amended from te toime, lam not adefautron account of non-payment of bil for ary telecom services provided by any service provider. nthe event of any dispute ‘onoering any telecom line, apparatus ot appliance, bil et, between melus and BSNL, the matter wil be refered to the sol Arbitrator, appointed by a rominaled auhoiyin BSNL and shall be governadby to provisions ofthe Arbivaion and ConclaionAct, 1996. ‘Signature of Customer! Authorized Signatory ‘Signature of Customer/ Authorized Signatory Signed on Date:‘TERMS AND CONDITIONS 41, Booking willbe confirmed subjectto feasibility BSNL shall have the sole discretion to accept or rejectthe application without assigning any reasonin case the application is rejected the deposit Shallbe refunded tothe applicant 3. The STB the ONT with power backup and the accessories (remote and cable wire) shal be sololy used for availing tiple play FTTH services of BSNL and shall natbe used for avaling services of any other network 4. The Set Top Box, the ONT with power backup and the accessories(remote and cable wire) shall be used for viewing authorised channels programmes and services ‘5. The subscriber shall take adequate care of STB and the ONT with power backup and is accessories during the perio ofthe agreement. Any willl defect or damage to STB and the ONT with power backup or is accessories wll be on account ofthe subscriber. 10 Meter cat 5 cable's {tee Extra @Rs.20 per meter 6. The Subscriber shallnot wthout the prior authorisation of BSNL remove, transfer or otherwise relocate the ST anc the ONT with power backup from the original place of installation faling which the deposit shal be forfeited and BSNL shall be entitled to recover the costo the STB and /or initiate legal action. 7. Incase of STB and the ONT with power backups lost or damaged on account of thet burglary orby any other accident the subscriber shallfle a police complaint forfnwith and natiy BSNL of such loss immediatly failing which BSNL reserves the righ fo recover the cost of STB and the ‘ONT wih power backup from the subscriber. 48, Incase ofnon payment or delay in payment of rentals BSNL shallraserve the right to cancelisuspend the earvce and to discontinue the service. In such cases the subscriber shall return the STB and the ONT with power backup in good working condition failing which the deposi shall be agjsted towards the costof the STB and the ONT with power backup. 9. FTTH plans are applicable as per plans and can be changed without any prior information to the subscriber within the scope of DOT / TRA) ‘guideline. 410. The pay channel fee.as prescribed rom mato time for each selected shal be paid 11. The subscriber shall in advance notiy change of adress contact number to BSNL or ts authorised representative for future correspondence context 12, Incase the subscriber desires to discontinue the services he shallretumn the STB and the ONT with pawerbackup in good working candlion 18. For reconnection/actvation of the FTTH service earlier disconnected for any reason the subscriber shall pay reconnection charges as prescribe from time to time. 14, IPTV servicesin respectof pay channels shallbe available fo the subscriber subject to force majeure condition including but not ited to act of God, fio, stinks, embargoes, war, insurection, riots and other causes beyond the reasonable control of BSNL including atmospheric Ropographical hindrances 16. Subscribers are not authorised to install any gadgets on STB and the ONT with power backup without BSNLs prior writen permission. The Ssubsenborhasto protect tho STB and ONT with power backup 16. Subserber shall not be entilld to transfer or assign its obligations and lablties under the terms and conditions to any other party under any Circumstances without prior permission of BSNL. Any transfer affected in contravention of the expressed terms contained herein shall not absolve the subscriber ofits obigaton/lablity towards BSNL. 17. Alltaxes, levies, etc present anc future shallbs tothe account of subscriber as applicable, 18. FTTH services qualty or functionality, availabilty andor reliability may be affected and for BSNL is enticed to, without any liability, refuse, fmt Suspend vary, esconnect and or interrupt tha services; in whole or in part al ary time ints sole discration with respect to onelal subscrbers, without any notice orreasons. 19. Incase of misuse of services or breach of any terms and conditions by he subscrber or use of services bythe subscriber in such a manner thatit Violates any laws or adversely affecs or interferes with BSNL FTTH services, company shall give notice of fve(5) days to the subscriber to romedy the breach. In case the Subscriber fais to remedy the sald breach within the notice period, BSNL shall be entitled to discontinue the service forthwith 20. BSNLFTTHatits sole ciscretion may be suspendidiscontinue the services by giving reasonable notices to subscriber. 21. FTTH service is lable for disconnection partially or otherwise duet: a. Changesinthe law, rules, regulations or orders, direction, notifications ecby the Authorities . Physical obstruction, geographic, topographic, hydrological, meteorological and other causes of cable interference or faults in other [Network f International Carrer towhich the Network connected, Any discrepancies/wrong particulars provided by the Subscriber. 22. Any dispute of diference of any nalure whatsoever or regarding any right, labilty, act, omission on account of any ofthe partes hereto arising ‘ut of or in relation to this terms & conditions shall be settle by arbitration in accordance to BSNL. However subscriber has right to appeal to exthigher authority 23. The valiity, construction and performance of terms and conditions herein shall be governed by and interpreted in accordance with prevailing laws. BSNLand Subscriber agroe to submitto the exclusive jurisdiction of the Delh courts. 24, Ihereby undertake that | wil fuly abide by Indian copyright Act 1994 as amended form time to time, | wil not indulge in pferagelcopy of the Content ete as prohibited by the aw. In the even of such vielaton, civ or eriminal action may instituted fo injuncton, actual damages (including Infringer's prot) et. 25. Availablity of Audlo-in and Video-in parts in TV will be the sole responsibly ofthe subscriber (Audio-in and Video-in ports are required for interfacing the STB). 28, The customer is required to fully comply with the provisions ofthe Indian Telegraph Act, 1985 and Information Technology({T)Act, 2009 an the Indian Telegraph Rules made there under and any amendments replacements made there to from time to time. 27, The contract with BSNL for provision of FTTH Broadband services willbe fr a minimum period of 3 months fom the date of commencementin accordance wth tariffpian opted. We have read and understood the terms and conditions provided overleaf and acknowledge thatthe tart plan selected and /WE agree tobe bound by the same, lWe agree to abide by the provisions of BSNL and there under ane as also such amendments as may be made from time to time to these rues in sofatas they relate to the services. We hereby declare and confirm thal the above information provided by malus sire totally correct and ruein every respect. Place: Signature of Subscriber