Customer Subscription Form for Railwire Broadband

Toll Free No. : 18001039139

CAF No. : TN72880107300

Loc

Type of connection Individual Corporate Railway/Railtel Central/State

Defence

APPLICANT DETAILS (Please fill information in CAPITAL LETTERS only)

First Name Middle Name Last Name
1. Applicant'S Name Mr Ms
A N I T H A B A B U

2. Name of Firm

3. Gender Male Female Other 4 . Nationality I N D I A N

5. Father's/Husband
Name
B A B U

6. Date of Birth 0 4 0 1 1 9 7 1 7. PAN NO A T E P A 4 8 7 1 C

8. Marital Status Married. Single. 9 . Existing Customer Yes. No.

10. Proof of Identity Driving Licence. Passport. Voter ID Card Aadhar Card Govt. ID Any Other Aadhar Card

11. Proof of Address Driving Licence Passport Ration Card Latest Tele/Electricity Bill Any Other HOUSE TAX RECIEPT
13. Installation Address 13. Billing Address

10th CROSS 1STREET PERIYAR NAGAR SAKKOTTAI 10th CROSS 1STREET PERIYAR NAGAR SAKKOTTAI
City KUMBAKONAM Pincode 6 1 2 4 0 1 City KUMBAKONAM Pincode 6 1 2 4 0 1

Landmark UNION BANK SAKKOTTAI Landmark UNION BANK SAKKOTTAI

Mobile No 8 9 3 9 4 4 8 2 3 1 Mobile No 8 9 3 9 4 4 8 2 3 1

Tele No Tele No

Fax No(For Fax No(For

Corporates) Corporates)
E-mail ID anithamuscat@gmail.com E-mail ID anithamuscat@gmail.com

14. Services/Plan & No. of Connections

Package FUP50Mbps-2Mbps 500GB x3 Port Speed 51200 Proposed Usage/Moth(MB) 512000

Services 1 2 3
Services 4
15.Payment Details

Amount Paid INR 499.00 (in words) Four Hundred And Ninety Nine Only

Mode of Payment Cash Cheque/DD Debit/Credit Card Cash Receipt No 1 4 9 / 2 3

DD / Date
Bank Branch
Cheque No

Declaration : I have read ,understood that the service(s) opted by me,as above,shall
be provided in accordance with the terms and condition overleaf and as published
in www.railwire.co.in/termsofservice.htm and agreed to abide by them.i shall be
solely responsible of all payments to words my subscription(s) Company Stamp
Signature of
Customer/Authorized Date 2023-07-23
Signatory(Mandatory)
 16. For Office Use Only

Custom MAC
Documents Attached Rilwire Activation
ID
Address
ID Proof Aadhar card House Tax r Photo Access Provider FS MAC ID
Proof
FSE Sign
FSE Code Wired Provider BS MAC ID
and Dt
ASM Code Wireless Provider FS Port
CRM Cordination Sign and
Activation Date BS Port
Dt
payment Realization date feasibility check Dt Feasible Not Feasible
17. FOR PARTNER USE ONLY

I/We hereby undertake and confirm I/We have activated the connection I/We have received the subscription
that i/We have seen the customer only after verifying that the form duly verified by ANP & MSP
and ceritify that -(a) The Customer customer has filled the subscription along with self attested copy of ID
Subscription From has been duly form and submitted copies of the proof & Address Proof and Photo
filled by the applicant (b) The required documentary proof.
photograph submiited has been RailTel's
matched with the applicant (c) The MSP's Representative ..................................
form has been personally signed by Stamp and .................................. Name
the applicant in my presence. Name Signature ..................................
(d)Proof of identity and Address has Signature of Designation ..................................
..................................
been collected .(e) Original proof of MSP Date ..................................
identity and address has been MSP Code ..................................
matched and verified with the self Date ..................................
attested documents submitted by
RailTel
the applicant (f) Details of
Customer subscription form match Managed Service
with all documents. Provider(MSP)
ANP's
Stamp and ..................................
Name
Signature of
ANP
..................................
(Mandatory)

Access Network
Provider(ANP)

RailTel Corporation of India Limited (a government of india undertaking.Ministry of

Railways)
रेलटेल कॉरपोरेशन ऑफ इंडया लमटेड (भारत सरकार का एक उपम। रेलवे क मी)
corporate office:143, Institutional Area, Sector-44,Gurugram - 122003
Registered office: 6th Floor,III3rd Block,Delhi Technology Park Shastri park,Delhi 110053
CIN:U64202DL2000GOI107905

https://www.railtelindia.com a retail broadband services RailTel Corporation of India Limited https://www.railwire.co.in