Regn No: …………..

NEPAL TELECOM Date: ……………….

(NEPAL DOORSANCHAR COMPANY LIMITED)
Kathmandu Regional Directorate
Service Division Lease No: …………
Date: ……………….

PP
Copper Pair Details
DATA / Internet / Intranet Application Form SP
Installed On
Test Period Start Date
Billing Period Start Date
User / Company's       (In BLOCK Letter)
Name:-
User / Company's Address Service Required:
Ward No.       Data Service
House No.       Internet Service
Street Name       Intranet Service
Tole Name       Do you already use NT lease
Zone       services Yes No
District      
V.D.C./Municipal      
ity
PAN Number :       Required Capacity
Contact Tel. No.       64 kbps
:
128 kbps
Contact Person :       256 kbps
Correspondence Email :      
512 kbps
User's Father's/Husband's      
Name :
1 Mbps
User's Grandfather's Name :       2Mbps
User's Identification: - 4 Mbps
Citizenship / Passport No.       Other Please Specify      
:
District :      
I hereby confirm that all above statements are true and correct. I agree to abide by terms, conditions an
call charges of
Nepal Telecom applicable as on date and as amended from time to time. I am fully aware that I will be
responsible for any misuse of service with or without my knowledge, and as per Telecom Act 2053, Claus
43 (Ga), Nepal Telecom may discontinue the services, in case of unauthorized uses.
 Signature:       Name:      

Designation       Office Name:      

Office Sea

No of IPs Required:
No of IPs Issued:
Other Lease Numbers Used by the Subscriber: