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CORPORATE CONNECTIONS VERIFICATION FORM

Customer Application Form no__________________________ Customer Application Date _________________________

Purchase Order No_______________________________________ Purchase Order Date_________________________________

Company Name: of M/S. VIZAG HOME SERVICES


Count of Connections requested for: 06
Company Address (From where PO released): 46-18-28/A DONDAPARTHI__ MANDAVARI STREET________
_________________________________________________________________________________________________________________________________

City: VISAKHAPATNAM State: ANDHRA PRADESH Pin Code: 530016

Landmark: _____________________________________________________

Authorized Signatory Name: MURAHARIRAO SUJATHA


Auth. Signatory Designation: PARTNER

Auth. Signatory Contact No: 7386785785

Auth. Signatory Signature_________________________________________

Company Stamp________________________________________________

__________________________________________________________For JIO representative use only_________________________________________________

I hereby confirm that I have met the Authorized signatory and the information furnished here is basis my visit done at
above mentioned address.
Executive Name: SATYA MADHAVI GUDLA
Visit Date__________________________________
Executive mobile number: 77803-75506

Executive Sign______________________________

Stamp ________________________________________________ (only in case of Agency/JIO partner)

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