BTRC RUIM/SIM FORM (A) 2010

nKmwqPfr k´P~J\Pj xÄrãe TÀj

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mO≠JñMKur ZJk pJYJATíf kJxPkJat

Thumb Print a
xJAP\r ZKm
IKlx TKk (Office Copy) Verified passport
size photograph b
V´JyT Kjmºj lro/User Registration Form
ßkJˆ-ßkAc (Postpaid) Kk´-ßkAc (Prepaid)

Form Serial No. KmâP~r fJKrU (Date of Sale): D D M M Y Y Y Y

ßoJmJAu j’r (Mobile No.): 0 1 5
1Ç V´JyPTr jJo (mqKÜ/ k´KfÔJj/ Ik´J¬ m~Û)
Subscriber Name (Individual/Organization/Minor) BLOCK LETTERS:

2Ç Ik´J¬ m~ÛPhr ßãP© IKnnJmPTr jJo

3Ç IjMPoJKhf k´KfKjKir jJo (k´KfÔJPjr ßãP© k´PpJ\q)
Authorized Person's Name (Applicable for Organization)
4Ç \JfL~ kKrY~k© j’r C (Ik´J¬ m~ÛPhr ßãP©-IKnnJmT) (National ID For Bangladeshi citizen)
kJxPkJPatr TKk /Copy of Passport: (For foreigner)
5Ç \jì fJKrU (Date of Birth) (Khj/oJx/mZr) D D M M Y Y Y Y kMÀw (Male) oKyuJ (Female)
6Ç ßkvJ (Occupation): xrTJrL YJTárL (Government Service) ßmxrTJrL YJTárL (Private Service) mqmxJ (Business) ZJ© (Student) IjqJjq (Other)
7Ç KkfJr jJo (Father's Name):
8Ç oJfJr jJo (Mother's Name):
9Ç * ˝JoL/˘Lr jJo (Spouse's Name):
10Ç ** xjJÜTJrL (Identifier): i) jJo S ßlJj j’r (Name & Phone No):
ii) \JfL~ kKrY~k© j’r (National ID No):
11Ç ˙J~L KbTJjJ (Permanent Address): lîqJa jÄ (Flat No) mJKz jÄ (House No) xzT jÄ (Road No)
V´Jo (Village)/FuJTJ (Area) CkP\uJ (Upazila)/gJjJ (Thana) ß\uJ (District)
cJTWr ßTJc (Post Office Code) \JfL~fJ (Nationality)
12Ç mftoJj KbTJjJ (Present Address): lîqJa jÄ (Flat No) mJKz jÄ (House No) xzT jÄ (Road No)
V´Jo (Village)/FuJTJ (Area) CkP\uJ (Upazila)/gJjJ (Thana) ß\uJ (District)
cJTWr ßTJc (Post Office Code)
13Ç Kmu ßk´rPer KbTJjJ (Billing Address): ÊiMoJ© ßkJˆ-ßkAc Fr \jq (For Postpaid Only) ˙J~L KbTJjJ (Permanent Address) mftoJj KbTJjJ (Present Address)
* A-ßoAu (E-mail)

IJKo FA oPot k´fq~j TrKZ ßp, CkPr k´h• IJoJr xTu fgq S CkJ• xKbTÇ ßTJj irPjr náu fgq k´hJPjr \jq IJKo IJAjf hJ~L gJTm FmÄ IJKo Ikr kOÔJr Kj~o S vftJmuL ßoPj YuPf mJiq gJTmÇ
(I do hereby declare that the Information and data given above are correct. In case of any false information, I shall be liable to appropriate legal action & I shall abide by the overleaf terms and conditions.)

IJPmhjTJrLr ˝Jãr (Applicant's Signature) fJKrU (Date) k´KfÔJPjr xLu (Organization Seal)

IKlKx~Ju mqmyJPrr \jq (Official Use Only)

ßoJmJAu j’r (Mobile No.): 0 1 5 Kxo KˆTJr (SIM sticker):
Kxo jÄ (SIM No.): 8 9 8 8 0
KmâP~r fJKrU (Date of Sale): D D M M Y Y Y Y
KcKˆsKmCaPrr jJo S ßTJc (Distributor's Name & Code):
KrPaAuJPrr KbTJjJ S ßTJc (Retailer's Address & Code):
KmPâfJr jJo (Name of the Salesman):

Kmâ~TJrLr ˝Jãr (Salesman's Signature): fJKrU (Date) xLu (Seal)

hsÓmq (Note): (a) TáajLKfTPhr \jq GKòT (Optional for Diplomats), (b) KmPâfJ \JfL~ kKrY~kP©r xJPg ZKm pJYJA TrPmj (Photograph to be verified by Salesman with NID),
(C)
\JfL~ kKrY~k© KrPaAuJPrr KjTa k´hvtj FmÄ kKrY~kP©r lPaJTKk xÄpMÜ TrPf yPm (Natlonal ID to be presented before the Retailer and a photocopy of the same
should be enclosed) (*) GKòT (Optional item) (**) TëajLKfT S KmPhvLPhr \jq GKòT (Optional for diplomats and foreigners).