Circuit No. Allotted:: - Telecom Circle - Telecom Distt

___________ Telecom Circle
____________ Telecom Distt.
Circuit No. Allotted:

_____________________
APPLICATION FOR LEASED CIRCUITS
(ONE APPLICATION PER CIRCUIT)
From (Applicant)
_________________________
_________________________
_________________________
_________________________
To
The Commercial Officer
O/o General Manager Telecom
_________________________
Date of Application______________
1.
The following Leased Circuit is required (Tick whichever is applicable)

i) Voice circuit
Telegraph Circuit
Data Circuit
Voice-cum-Data Circuit
Non Exchange line Private Wire
Junction (2 mbps) link for ISP service or any other service
From (Complete Address____________________________________________ (A end)
___________________________________________________________________________
___________________________________________________________________________
To (Complete Address) ________________________________________________ (B end)
___________________________________________________________________________
___________________________________________________________________________
ii) Local Intra City

Intra SDCA
Long Distance
International
iii)
Temporary (mention period of hire: days/months) __________________ Permanent
iv)
Full Time
Part Time (mention time periods)
2.
The purpose for which the above circuit is required:Specify
i) Voice
Data
Telegraph
Facsimile
Circuit for Internet connection from BSNL
Circuit for Internet connection from other ISP
(Please give name of ISP)
(Please tick more than one box if the circuit is to be used for more than one service)
ii)
Is the Internet circuit required to be terminated on private network

Yes
No
3.
Please mention Telephone No(s) working at the premises at each end

(A end)______________________ (B end)________________________
4.
Status of the applicant: (please tick relevant item)

i)
iii)
v)
vii)
Limited Co.
Government
Statutory Body
Others
ii)
iv)
vi)
Public Sector undertaking

Public Institution
Society/Trust
5.
Additional information in case of a data circuit i)

Speed of operation ___________ Kbps/Mbps
ii)
Type & make of modem (if subscriber owned)______________________
(Enclose literature if the proposed model in not approved by TEC)
iii)
Type of circuit 2-wire/4-wire____________________________________
(Tick whichever is applicable)
iv)
Request of IP address:
(Form A to be filled up)
Note: IP addresses need to be utilized within 15 days of assignment.
6.
General information required for any type of circuit.

i)
7.
8.
Whether the circuit is: Point to Point circuit

Network Circuit
(If it is a network circuit, diagram of approved network to be enclosed. If network
approval in not available, please submit your application to
_______________________O/o CGM ________________ Telecom Circle
______________________________________ (address). If already applied submit a
copy of application. Application may be registered and demand note issued for
payment. Circuit will be provided only after network approval is obtained.)
Diagram enclosed
Yes
No
Please mention the network approval reference number ______________________
__________________________________________________________________)
ii)
Hirer/main hirer of the circuit/network: (name & address)_____________________
____________________________________________________________________
____________________________________________________________________
iii)
The following subscriber owned equipment is proposed to be used on the circuit and
the concerned technical literature is enclosed. _______________________________
___ _________________________________________________________________
(Equipment connected on the circuit in addition to the modem/private automatic
exchange/telephone instrument/relay set should be mentioned here)
The following additional equipment/attachments are required _________________________
I/We desire to have General Manager ___________________________________________
as the controlling and billing authority.
9.
Correspondence address & Name of contact person _________________________________

___________________________________________________________________________
Fax ________________________________ E-mail ID______________________________
10.
Billing Adrress______________________________________________________________
___________________________________________________________________________
11.
Any other relevant information the applicant wants to state.

___________________________________________________________________________
___________________________________________________________________________
12.
List of circuits already working in India for our organization (Complete details of local/long
distance circuits to be furnished. Please attach additional sheets, if necessary).
A End
B End
CCt. No./Regn. No.
Billing & Enrolling

Authority at A end /
B end and Telecom
Unit-specify
(Enclose separate list if space is not sufficient)

13.
DECLARATION
i)
ii)
iii)
iv)
v)
I/we hereby agree to abide by the provisions of Indian Telegraph Rules in force and as
modified from time to time and such other terms and conditions prescribed by the telegraph
Authority/BSNL. I/We agree that the circuit will be used purely for private/permitted
application. It will not be used to carry voice/data or any other communication, which is not
permitted by the rules of Telegraph Authority/BSNL. I/We further agree to extend facility to
the Telegraph authority/BSNL in order to enable monitoring of the purpose, performance and
operation of the circuit, as and when required.
I/We agree that necessary charges for registration/installation/Advance annual rental/Arrears
if any will be paid to the controlling/billing authority. BSNL, __________________ Telecom
District as and when we receive demand note. As and when such charges become due.
I/We agree that i/We shall pay the cancellation charges and other expenses incurred to
establish the circuit as requested by me/us that may become payable, in the event of
cancellation of the application/closure of the circuit at a later date.
I/we Agree to use the leased circuit for the minimum period of hire as specified by the BSNL.
I/We declare that the information filled up by me/us in the form are correct and no
information has been withheld. If the information is found incorrect subsequently, BSNL will
have the right to take any action deemed fit including denial/termination of service.
Place________
Date________
__________________________
__________________________
__________________________
(Signature, Name & Address of the Applicant)
14.
Important instructions for filling up of the form:i)

ii)
iii)
iv)
v)
15.
The form may be filled up in Capital letter only

In the absence of PAN/GIR number, declaration in for 60/61 may be furnished in the
enclosed proforma.
In case of sole proprietary concern, proprietor may sign himself and affix rubber
stamp.
In case of partnership concern all partners or any one of the partners duly authorized
or Person with the Power of Attorney may sign. In case of company, signature should
be of a person on behalf of a Company in accordance with the provisions of its
Articles of Association. In case of Partnership concerns, copy of (I) power of
Attorney for authorization & (ii) Partnership Deed, and incase of Limited Company, a
copy of the Articles of Association may be attached.
In case of Government Department, Authorized person may sign and affix rubber
stamp.
Please mention list of enclosures:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
For Official use

1. Demand Note No.__________________________ Date __________________________
2. Amount Rs _____________________________________________________________
3. Mode of Payment : ______________
Cash/ Cheque
(Cheque No________________ Date________)
4. Circuit No. Allotted._______________________________________________________
5. Date of Commissioning____________________________________________________
6.
Frequency of payment (yearly/quarterly)____________________________________

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___________ Telecom Circle

____________ Telecom Distt.

Circuit No. Allotted:

The following Leased Circuit is required (Tick whichever is applicable)

ii) Local Intra City

Is the Internet circuit required to be terminated on private network

Please mention Telephone No(s) working at the premises at each end

Status of the applicant: (please tick relevant item)

Public Sector undertaking

Additional information in case of a data circuit i)

General information required for any type of circuit.

Whether the circuit is: Point to Point circuit

Correspondence address & Name of contact person _________________________________

Any other relevant information the applicant wants to state.

CCt. No./Regn. No.

Billing & Enrolling

(Enclose separate list if space is not sufficient)

Important instructions for filling up of the form:i)

The form may be filled up in Capital letter only

Please mention list of enclosures:

For Official use

3. Mode of Payment : ______________

Frequency of payment (yearly/quarterly)____________________________________

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