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Part-A

 NEXT FONE LIMITED
Next Fone Ltd. Plot 325, Lane 22, New DOHS, Mohakhali, Dhaka 1206
Call 09614 121121, 880 2 8815468
www.nextfone.com.bd
REGISTRATION FORM
(Pre-paid/Post-Paid/ Others.......................)		 BTRC Form: 2006
Two Passport Size Photograph to be Attested by 1st Class Gazetted Officer/ Operators’s Representative/ Authorized Seller
Form Serial Number:........................ Issued IP Telephony No: 09614.......................................
1. User Individual/Company’s Name: (In Bangla)
 ....................................................................................................
(In English)
2. User Name(In case of Company): (In Bangla) ....................................................................................................
(In English)
3. Date Of Birth:
Age:
Years:
  
 
dd
mm
 year  
4. Gender: Male/Female:
5. Occupation:
6. Nationality:
7. Permanent Address:
8. Present Address (for IP Telephony subscriber):
9. Contact Number: Tel:
Mobile:
Email:
Fax:
 Any Others:
10. Father’s Name: (In Bangla) ........................................................................................... (In English)
11. Mother's Name: (In Bangla) ........................................................................................... (In English)
12. Husband/Wife Name (If married): (In Bangla) ...................................................................... (In English)
13. Second Contact:(Name & Address): Mobile/Tel No:
14. All Mobile /Land Phone numbers under his/her possession:
15. Photo Identity Document: Card/Driving License/Passport/BTRC form: 2006(A)/Any Other Identity Document with Photo)
16. Existing Broadband Provider: Bandwidth:
Operator's Representative/Authorized Seller
I have personally verified the attached photograph
and identity of the application.
User
I hareby declare that the information given above is correct. In case of
any false information , I shall be liable to appropriate legal action.
   
Sign With Seal:
Name and Address:
Date		 Sign :
Date:
Seal (If Company):
Note:
1. The applicant must complete all serials of this Form and any incomplete Form will not be accepted.
2. For item serial 15. Original ID to be presented before the seller and attested photocopy of that same should be submitted. If the applicant doesn’t have the ‘Photo Identity Document’, then duly filled up BTRC form: 2006(A) is to be presented before the seller and attested photocopy of the same is to be submitted.
3. In case of asterisk (*) marks, information regarding Bangladeshi citizens to be given both in Bangla and in English.
 

Part-B
1. Company Authorized Person: ...............................................................................  Designation: ........................................................................................
2. Contact Number: ...............................................................................  Billing Address:
3. Package Details: Pre-Paid .......................................  Post-Paid: ..................................................  Others: ..............................................................
This part to be filled by office
4. Device (Quantity): .................................................       ATA ( ) ......................................................
 IP Phone ( )
...............................................
 Soft-phone ( )
5. MAC Address/IMEI of the IP Phone/ATA/Dialup phone: ....................................................................................................................................................................
6. Seller’s Name: .....................................................................................................................................................................................................................................
7. Seller’s ID: .....................................................................................................................................................................................................................................
8. Seller’s Contact No: ....................................................................................
Next Fone IP Phone number:
 ...........................................................
   
Paid Amount Tk.
 ............................................................
   
Paid Amount In Word
............................................................
Please preserve this form for future reference
Please preserve this form for future reference[Terms & condition over leaf]