Local/LD/DOV/PW........Regn. No. ............................................................. Speed..............Wires...............D.Note No. ....................P.R. No..............

Application Form No. .......Price Rs.10/-

(One Application Form Per Circuit)

(Please read the instructions attached before filling up the form)

Type of Circuit : (a) Local/Long Distance............. (b) Speech/Data/TP/Ticker/Others/R&G Cable/Tie Pair

1. Name and Permanent Address : ......................................................…........................................................

of the Applicant ......................................................…........................................................

2. Name and Address where main end (A) is : ......................................................…........................................................

to be terminated (indicate Telephone No.) ......................................................…........................................................

Tele. No ......................................................…........................................................

(Any Tel. No. working in Bldg./Locality)

3. Name and Address where main end is to : ......................................................…........................................................

Tele. No. ......................................................…........................................................

(Any Tele. No. working in Bldg./Locality)

4. Billing Address of the Applicant :......................................................…........................................................

5. Telephone Nos. and Fax No. of the Applicant : (a) ......................................................…........................................................

(for contact purpose, Name & Designation) (b) ......................................................…........................................................

may be indicated) (c) ......................................................…........................................................

6. Particulars of Deposit made : Rs.1000/- (One Thousand only) by

1. Cash.................................
2. (b) D.D No............................. Date................................. Drawn on Bank........................Branch.....................................

7. In case of Partnership Firm

(a) Whether Registered/Unregistered : ....................................................

(b) Names, in full, of Partners :

1.. ......................................................…..........................................................................................................................................................................

2..........................................................................................................................................................................…........................................................

3..........................................................................................................................................................................…..........................................................

(Attach additional sheet if space is insufficient)

1. *Local/Long Distance

2. *Speech (Private Wire) Extn./Teleprinter/Ticker.

3. Terminal equipment;‘A’ end......................................................…........................................................

4. Whether sub-owned/Departmental equipment required

(In case of sub-owned equipment, furnish copy of technical literature of equipment and equipped working capacity of boards etc.)

5. *Attachment for TP whatever is not applicable

(Note: *Strike out whatever is not applicable)

(B) Technical details of the Data circuit required

1. *(a) Type of Transmission : Data

*(b) Type of Circuit : 2 Wire/4 Wire 

2. *Type of working (for dedicate circuit: Point to Point/Network Basis)

(In case of Network please indicate Name of the network...............................& valid upto.............................)

3. *Whether Departmental/Subscriber owned : Departmental/ modem/Fascimile equipment will be used Subscriber owned

4. (a) Description of : ‘A’ end

Terminal equipment ‘B’ end

(b) No. of Terminals at : ‘A’ end

5. Speed of operations circuit :

6. (a) Type and model of modem :

(b) Manufactured by :

(c) Speed of operation :

(d) If sub-owned indicate : (a) Readily available ...............

(b) Will be availed by ......................

7. The Network will consist following circuits and No. of terminal as detailed against each. (*Mark whichever is applicable).

1. Name & Type of EPAX/EPABX :

2. N O C obtained from MTNL

3. Copy of latest paid bill of Tele.Nos. in case of EPABX

4. A letter certifying that no Long Distance Speech/Data circuit is

terminated on our EPABX/EPAX and will not be terminated in future.

1. Detailed schematic diagram

2. Network approved letter

3. Interface approved certificate if the modem is not in approved list.

1. Type of cable

2. Size & Gauge

3. Approximate length

4. End terminations

5. Usage details

VI. Give details of all non-exchange lines existing/proposed from either of (A) of (B) of Page No.1 in separate sheet with schematic diagram (Also please indicate Telephone Nos. used with modem facility). 

VII. I/We agree to abide by the provision of Indian Telegraph Rules in force and as modified from time to time and such other terms and conditions prescribed by Telegraph Authority/MTNL. The facility to monitor the circuit will be extended by me/us to Telegraph Authority/MTNL for monitoring purpose, performance, operation etc. of the circuit. This circuit will be utilised for the banafide use as indicated above.

The information given above, along with this is correct and true to the best of my/our knowledge and belief.

Place Name & designation Signature

Date:

(Authorisation letter may please be got attested)

(Please attach additional sheet if necessary)