P.O.

Box 1047 Addis Ababa Ethiopia

tel.: +251 (0) 115 505 678
fax: +251 (0) 115 515 777

Application Form for Device Installment Sales/

በረዥም ጊዜ የሚከፈል የቴሌኮም መገልገያ መሳሪያ ሽያጭ ማመልከቻ ቅፅ
Customer's Information/የደንበኛው መረጃ
Customer Type: Individual Enterprise
የደንበኛው አይነት ግለሰብ ድርጅት
Customer Name፡ ______________________________________________________________________
የደንበኛው ሥም፡
Sex Female Male Nationality: _________________________
ፆታ ሴት ወንድ ዜግነት
Address: Region: ____________ Zone: ___________ Woreda፡ ______ Kebele፡ ______ H.No፡ ________
አድራሻ ክልል ዞን ወረዳ ቀበሌ የቤ.ቁ.
Contact Name: __________________ Position/: ____________________ Phone: _________________
የተጠሪ ስም ስራ ስልክ
Email: ___________________________ TIN: __________________ VAT Reg.: ___________________
ኢሜይል ግ.ከ.መ.ቁ. ተ.ዕ.ታ. ምዝገባ
Guarantor Company Name (If applicable): ___________________________________________________
የዋስትና ሰጪው መስሪያ ቤት ስም (አስገዳጅ ከሆነ)

Service Information /የአገልግሎቱ መረጃ

Account Number: ______________________________

የአካውንት ቁጥር
Service No: ______________________________
የአገልግሎት ቁጥር

Installment Device Sales Information/በረዥም ጊዜ የሚከፈል የቴሌኮም መገልገያ መሳሪያ ሽያጭ መረጃ

 Device Model: ____________________  I.M.E.I. No.: _____________________

የመገልገያው መሳሪያ አይነት አይ.ኤም.ኢ.አይ.

 Upfront Payment: ____________________  Serial No.: ____________________

ቅድመ ክፍያ ተከታታይ ቁ.

 Installment Period: ___________________  Monthly Payment: ___________________

የክፍያው ጊዜ ርዝመት ወርሃዊ ክፍያ፡

 Contract Plan (If any): ____________________  Device Quantity: ___________________

ኮንትራት ፕላን (ካለው) የመሳሪያው ብዛት

I hereby confirm that the information given above is accurate and take full responsibility if the information is
found to be false/ ከላይ የተገለፀው መረጃ ትክክል መሆኑንና መረጃው የተሳሳተ ሆኖ ከተገኘ ሙሉ ኃላፊነቱን እንደምወስድ አረጋግጣለሁ፡፡

Region/Zone: __________________________ Shop Name: _____________________________

ሪጅን/ዞን የሽያጭ ማዕከሉ ስም

Customer/Authorized Person Authorized Person on behalf of Ethio Telecom

ደንበኛው/ተወካይ በኢትዮ ቴሌኮም በኩል ስልጣን ያለው/እንዲፈራረም የተወከለ/ች

Full Name: ____________________________ Full Name፡ ____________________________

ሙሉ ስም ሙሉ ስም
Position: ____________________________ Title: ____________________________
የሥራ ማዕረግ ማዕረግ
Signature: ____________________________ ID፡ ____________________________
ፊርማ የመ.ቁ.
Date: ____________________________ . Signature፡ ____________________________
ቀን
ፊርማ
Date፡ ____________________________
Stamp: ቀን
ማህተም

Note/ማስታወሻ
If agreement &/or guaranty is mandatory, signed agreement by the customer along with signed &/or sealed letter from guarantor should be attached with the application/
የውል ስምምነት እና/ወይም ዋስትና የግዴታ ከሆነ በደንበኛው የተፈረመ ስምምነት እና/ወይም በዋስትና ሰጪው ተፈርሞ ማህተም የተደረገበት የዋስትና ደብዳቤ ከማመልከቻ ቅፁ ጋር መያያዝ አለበት፡፡