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BHARAT SANCHAR NIGAM LIMITED
(A Government of India Enterprise)
CHENNAI TELEPHONES

DECLARATION FORM

FOR PROVISION OF DATAONE BROADBAND CONNECTION
I am having a BSNL's bfone connection with telephone number : ..........................................
I have registered for a  Broadband connection vide Regn. No :

Registration date

 : ..........................................
I would like to avail the starter pack HOME 500 with the option selected below
 

DATAONE PLAN HOME-500

Modem Option

 Amount  to be paid
in first bill
(in Rupees)

Option Selected
(Please tick in
appropriate box)
Customer Owned Modem
a. Monthly payment  option 551 box
b. Discounted Annual payment option  * 5510 box
Modem Purchased from BSNL
a. Monthly payment option 2635 box
b. Discounted Annual payment option  * 7594 box
Modem Rented from BSNL
a. Monthly payment option 1437 box
b. Discounted Annual payment option  * 6396 box
* On payment of Rs.5000 (which is included in the Discounted Annual Payment option)
Monthly Plan Charges need not be paid for one year
I hereby declare that the initial up-front payment of   Rs.(in figures)    ______________________  
(Rupees _______________________________________________________________) only
can be collected through the first  / next   Telephone Bill of the Telephone Number  for which the
Datone Broadband connection has been given   

 

Signature of Customer / Authorised Signatory  : .....................................................
   NAME  (in block letters) : ....................................................
(Affix rubber stamp of firm or company
if Authorised Signatory for firm or company)
 :