CUSTOMER APPLICATION FORM Fill in Block Letters

First Name *
Middle Name
Last Name *
Contact Info

Home Contact No.(With STD Code)
Office Contact No.(With STD Code)
Mobile * (+91)
 
Installation Address

Door/Plot No *
Apartment Name *
Address *
City *
Zip Code *
Land Mark
Billing Address If same as installation address, tick here / If different, then fill in the information below.

Door/Plot No *
Apartment Name *
Address *
City *
Zip Code *
Land Mark

USER PROFILE DETAILS

Note: Please write your email address clearly and legible. This will be used for correspondence and if it is not clear then it will be configured incorrectly. (Please do not give an email id which may change in the future.)

E-mail for Correspondence *
Personal Info

Date of Birth
Wedding Anniversary
House
If rented, Staying since
Profession
Purpose of Connection *
Do you need Static IP
ID & Address Proof *
Hardware at Customer End
Photo
Signature

PACKAGE AND PAYMENT DETAILS

Package Opted For
Package Pay Term
Installation Charges (Rs)
Subscription Charges (Rs)
Security Deposit (Rs)
Other Charges (Rs)
Total Amount (Rs)
Cheque No
Date
Bank
Amount
Temp. Receipt Info:

No
Date
Amount

FOR OFFICE USE

Note: Below information to be filled in by sales executive in consultation with concerned area team.

Account No.
Parent Account No.
Child Account
If yes, allocated to Parent
Installation Invoice Raised
Security Deposit Entered
Special Remarks, If any
Sales Executive Name
Sales Executive ID
Enquiry
Estimated Cabling