NEPAL TELECOM

(NEPAL DOORSANCHAR COMPANY LIMITED)

Kathmandu Regional Directorate

Service Division

Regn No: ..
Date: .
Lease No:
Date: .
PP
Copper Pair Details
SP

DATA / Internet / Intranet Application Form

Installed On
Test Period Start Date
Billing Period Start Date

User / Company's
Name:-

(In BLOCK Letter)

User / Company's Address

Ward No.
House No.
Street Name
Tole Name
Zone
District
V.D.C./Municipal
ity
PAN Number :
Contact Tel. No.
:

Contact Person :
Correspondence Email :

User's Father's/Husband's
Name :
User's Grandfather's Name :

User's Identification: Citizenship / Passport No.

:
District :

Service Required:
Data Service
Internet Service
Intranet Service
Do you already use NT lease
services
Yes
No

Required Capacity
64 kbps
128 kbps
256 kbps
512 kbps
1 Mbps
2Mbps
4 Mbps
Other Please Specify

I hereby confirm that all above statements are true and correct. I agree to abide by terms, conditions an
call charges of
Nepal Telecom applicable as on date and as amended from time to time. I am fully aware that I will be
responsible for any misuse of service with or without my knowledge, and as per Telecom Act 2053, Claus
43 (Ga), Nepal Telecom may discontinue the services, in case of unauthorized uses.

Signature:

Name:

Designation

Office Name:

Office Sea

No of IPs Required:
No of IPs Issued:
Other Lease Numbers Used by the Subscriber: