Application Form for Broadband Service (Data One) 1. Category of Applicant : □ Residential □ SOHO □ SME □ Corporate □ Whole Sale □ NGO □ Educational Institutions □ Government □ BSNL Service □ BSNL Employee 2. Name of the Applicant: Title Mr/Mrs/Ms/Dr First Name Middle Name Last Name (Fill in item 3, if you don’t belong to Residential/BSNL Employee category) 3. Name of the Company: ________________________________________________ (Fill in item 4 to item 9, if you belong to Residential/BSNL Employee category) 4. Date of Birth: _________________ (dd/mm/yyyy) 5. Gender: □ Male □ Female 6. Marital Status: □ Single □ Married 7. Educational Qualification: □ Doctorate □ Post Graduate □ Graduate □ Under Graduate 8. Profession: □ Government Service □ Private Service □ Self Employed 9. Annual Income: □ less than 50000 □ 50000 – 100000 □ 100000 – 200000 □ 200000 – 300000 □ 300000 – 500000 □ above 500000 (Fill in item 10, if you are a customer of BSNL) 10. Consumer Number : 11. Existing BSNL Telephone number on which Broadband connection is required 0 12. Want to apply for a new BSNL Telephone connection: □ Yes □ No 13. Do you want this Broadband connection for temporary use: □ Yes □ No (Note: Tariff is different for temporary connection) 14. Type of Broadband use: □ Residential □ Business 15. Choice of Tariff Plan: □ Startup Plan 250 □ Home 500 □ Home 1000 □ Home 1800 □ Home 3300 □ Home UL 900 Plus □ Home UL 900 □ Business 700 □ Business 1200 □ Business 3000 □ Business 5000 □ Business 9000 16. Do you wish BSNL to provide modem: □ Yes □ No (Fill in item 17, item 18, only if your answer for item 16 is Yes) 17. Choose the Modem purchase option: □ Rental □ Purchase 18. Choose the type of Modem: □ Type-I □ Type-II □ Type-III □ Type-IV 19. Do you need a Static IP from BSNL: □ Yes □ No (If your answer for item 19 is yes, you will have to fill in a separate application for Static IP and submit along with this form) 20. Preferred Activation Date: _________________ (dd/mm/yyyy) 21. Choice of Data One access user-ids: (Note: The length of the user-id should not exceed 12 characters) 1. _________________ 2. _________________ 3. _________________ 4. _________________ 22. Choice of Email ID: (Note: The length of the user-id should not exceed 12 characters) 1. _________________@ bsnl.in 2. _________________@ bsnl.in 3. _________________@ bsnl.in 4. _________________@ bsnl.in 23. Choose the payment option: □ Monthly □ Annual 24. Billing Address: (Note: Address to which you want BSNL to send the Invoices) Address Line 1 : Address Line 2 : Area : City : State : PIN Contact Phone with STD 0 25. Address of Connection: Address Line 1 : Address Line 2 : Area : City : State : PIN Contact Phone with STD 0 26. Default Communication Address: □ Billing Address □ Address of Connection (item 24) (item 25) 27. Contact Email ID: _________________ (Any notification from BSNL will be send to the email id mentioned in item 27.) 28. Other contact numbers: (if any) Contact Mobile Number : Fax Number with STD : 0 29. Self Declaration: I have gone through the BSNL Broadband Internet Service Terms and Conditions and agree to abide by the same. Date: Signature Place: Applicant’s Name BSNL Broadband Internet Service Terms and Condition 1. Subject to the acceptance of the application and technical feasibility, BSNL will endeavor to provide the Broadband Service as soon as possible. 2. A Demand note will be issued to the customer for depositing the charges payable as per tariff plan selected for enabling the customer to pay the same before commencement of service. 3. The contract with BSNL for provision of Broadband Service will be for a minimum period from the date of commencement (depending upon the plan chosen) in accordance with the tariff plan opted. 4. The data rates shown as down stream or up stream are applicable only to last mile. However, BSNL shall not be responsible for lesser download speed or upload data rates caused by the accessed website status or the international gateway or the media. 5. Customers are free to choose their own modem from out of type approved models. 6. All IP addresses will be dynamic. 7. The Broadband connection will be withdrawn in case the customer surrenders BSNL telephone line. 8. Shifting of Broadband connections is subject to the technical feasibility and would be done on payment of applicable shifting charges. 9. The subscriber is required to fully comply with the provisions contained in the Indian Telegraph Act 1885, Indian Telegraph Rules and the Information Technology Act 2000 and any amendments or replacements made thereto from time to time. OTHER CONDITIONS: 1. Billing for the service will be included in the normal b-fone bill (Landline Phone bill). The billing cycle shall be same as b-fone cycle. 2. No migration is allowed to a lower tariff plan till the expiry of the committed period. RIGHT TO TERMINATE SERVICES: 1. BSNL reserves the right to disconnect the service to any customer in case there is sufficient evidence of the customer intentionally or unintentionally using the service in the manner which would adversely impact BSNL or BSNL's network. 2. The customer shall be responsible for using the service only for legal and appropriate purposes. 3. BSNL reserves the right to terminate the services in the event of non-payment of bills issued by BSNL in accordance with the tariff plans opted by the customer and the extent of usage or any default on the part of the customers. DISCLAIMER: 1. BSNL will exercise all reasonable care in providing its services, but it is not responsible for interruption in service due to power failures, equipment malfunctions, or acts of natural calamity. 2. BSNL is not responsible for subscriber's computer hardware and software or areas of the Internet not under its control. BSNL does not warrant privacy, security or efficiency of the Internet. 3. BSNL is not responsible for actions taken by its customers or others as a result of its services. 4. BSNL is not responsible for material any person (including household members of the subscriber) may receive or transmit via the Internet, or for anything bought or sold via the Internet, or for any other result of an action taken by anyone using its service.