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Falconet Internet Pvt. Ltd.

ISP LICENSE No. DS-11/333/2016-DS-111

Neelkanth Colony, Karnal Road, Pipli, Kurukshetra, Haryana 136131

Ph: 9896796084 | Web:- www.falconet.in | Email: info@falconet.in

Form Number:

Application for Registration
Area
 Subscriber’s Number Allotted
 Passport Size Photo
Full Name / Company Name
Father’s Name
Gender (M/F)
 DOB
 Nationality
Email
Profession of Subscriber
Installation Address
Permanent Address
Plan Details
Plan Requested Initially
 Amount Paid
 Mode
Cheque Details (If Paid by Cheque):
Cheque No.    Dated    Bank Name

I have gone through the terms and conditions...
ID Proof    Address Proof

Applicant Signature / Stamp
Rubber Stamp & Signature of Associate
I have personally seen and verified the customer and documents.
For Office Use Only

Received On: Verified On: Introducer:

Verified By: Account No.:

Log on Date:

Signature of Authorised Person