Bharti Airtel Limited (Mobile Services)

Customer Application Form no…………………………… Customer Application Date ……………………………….

Purchase Order No…………………………………………….. Purchase Order Date…………………………….

Sr. DESCRIPTION Detail

1 Name of company
2 Number of Connections requested*
*details of mobile numbers to be attached as per Annexure – I

Customer undertaking

I hereby confirm that an order for the mentioned mobile numbers has been placed and the user name along with their details is provided
against these mobile numbers as per the annexure1 containing ________pages.

I will update you on any name change happening in future due to transfer of mobile numbers, within a week of any such change.

________________________________________________________________
Customer Signature (Authorized signatory)

________________________________________________________________
Company Stamp

Annexure – I

Designation of
Mobile Name of POI Document POI Document Complete Address
Number End User Type of end User Number of end User of End User
End User

Note : Mobile number is mobile connections requested by the Authorized Signatory on behalf of bulk customer)

________________________________________________________________(all pages of annexure 1)

Customer Signature (Authorized signatory)

________________________________________________________________(all pages of annexure 1)

Company Stamp