BHARAT SANCHAR NIGAM LIMITED Digital KYC

(A Govt. of India Enterprise)

CUSTOMER APPLICATION FORM FOR MOBILE CONNECTION

www.bsnl.co.in | Help line : 1800 180 1503

CAF No* BD15832265 Mobile No alloted* 9427667481

Type of Connection* PREPAID

Type of Subscriber* INDIVIDUAL CAF No :BD15832265

POS Name :PATHAN AMJADKHAN DILAVARKHAN
1. Customer's name Mr/Ms* MAKADARAFIKBHAI POS Code :GJ15RET1338364

2. Father/Husband's name* HARUNBHAI Captured Date&time :24/01/2019 08:27:38

Please fill form Lat ,Lang: 22.4231,71.2007
3. Date of Birth/Age* 20/12/1970 4. Gender* MALE 60'/61'(whichever PAN/GIR is
applicable) given below in case
5. PAN/GIR* you do not have PAN/GIR
6. Alternate number 8200670598
If Foreign National
7. Nationality* INDIAN 8. Profession 9. Passport Number
10.Date of VISA expiry 10A.VISA Options : Tourist VISA Work Permit VISA
11.Bill to be sent to 12.Email ID

13. Present/Local Address* (As given in POA document):

House No/Flat No Police line
Street Address/Village Chotila

Locality/Tehsil Chotila State/UT GUJARAT

City/District Chotila Surendra Nagar Pincode 363520

14. Permanent Address : (To be filled in mandatorily by outstation customers, supporting POA document madatory)
House No/Flat No Police line

Street Address/Village Chotila

Locality/Tehsil Chotila State/UT GUJARAT

City/District Chotila Surendra Nagar Pincode 363520

15 Proof of identity details* 16. Proof of address details*

Type of POI Aadhar card(12 Digits) Type of POA Aadhar card(12 Digits)

Issuing authority UIDAI Government of India (GOI) Issuing authority UIDAI Government of India (GOI)

Date of issue 01/01/1900 Document No 668340721597 Date of issue 01/01/1900 Document No 668340721597
Place of issue Bengaluru Place of issue Bengaluru

17. Number of Mobile connections held in name of Applicant (Operator-wise)* 0

18. Tariff Plan Applied* MNP BASIC PREPAID 19. Value Added Services Applied(if any)
20. Services/Facilities required* STD,ISD,GPRS/MMS,National Roaming,3G,4G,Call
21. Payment Details (To be filled in cases of walk in customer)
21A. Mode of Payment: Cash Cheque Credit card Debit card

21B. If payment made by cash/cheque/creditcard/debitcard

a. Bank A/c No b. Bank Name

c. Branch Name & Address

22.Local reference (For National outstation and Foreign National customers)
Name Contact No
Address

Calling party's No

23.To be filled in cases of Mobile number portability (MNP)

23A. UPC VG543817 23B. Previous Service Provider & Licensed Service Area Details VODAFONE GUJARAT

Declaration by subscriber
(A). The information provided by me is correct.
(B). OTP validation to the given alternate number ca be treated as my signature.
(C). I have received the SIM card.

Fields to be filled by Service Provider/Authorized representative

24. IMSI No.* 404579101134463 25. SIM Number 8991571192912134463

26. Point of Sale Code* GJ15RET1338364 26A. Point of Sale Name* PATHAN AMJADKHAN DILAVARKHAN

27. Complete Address of Point of Sale* (To be populated by Licensee)

House No/Flat No* pathan manjil chamunda road,

Street Address/Village shivam narshing hom

Locality/Tehsil* ,Chotila ,Surendra Nagar,

City/District* SURENDRANAGAR State/UT* GUJARAT Pincode* 363520

Declaration by BSNL staff

It is certified that i have checked the CAF as per the DOT guidlines and entered the subscriber details correctly in the BSNL Database
Date* 24/01/2019 03:00:18 PM Name* ASHISH J ZINZUWADIYA(200305776 ) Code* GJ15400001

Declaration by BSNL employee activating the mobile connection

(a) Certified that all the documentary requirement has been completed and subscriber details have been entered in the database before activation of the connection
(b) Details of Add-on/Value Added facilities as requested by customer and Tariff plan(s)etc. activated on the mobile number
Name* ASHISH J ZINZUWADIYA(200305776 ) Designation* JAO Date* 24/01/2019 03:00:18 PM
CAF Serial No:BD15832265 CAF Serial No:BD15832265

POS Name : PATHAN AMJADKHAN DILAVARKHAN POS Name : PATHAN AMJADKHAN DILAVARKHAN

POS Code :GJ15RET1338364 POS Code :GJ15RET1338364

Captured Date & time: 24/01/2019 08:28:18 Captured Date & time: 24/01/2019 08:28:18

Lat ,Lang: 22.4231,71.2007 Lat ,Lang: 22.4231,71.2007