From (Applicant) To
_________________________ The Commercial Officer
_________________________ _________________________
_________________________ _________________________
1. Name of Customer___________________________________________________________
2. Land Line Number: _____________________ 3. Account Number : __________________
4. Billing Address : ____________________________________________________________
__________________________________________________________________________
i) Mobile Number. :
ii) Email Id :
iii) Go Green Option for E-Bills: Yes / No
(If Yes, All the Bills will be sending to the Mail Id Mentioned above. Paper Bills will be discontinued)
6. DECLARATION:
I hereby declare that the details furnished above are true and correct to the best of my
knowledge and belief. In case any of the above information is found to be false or untrue or
Place: ________ __________________________
Date: ________
(Signature, Name of the Applicant)
Encl: Please enclose a
valid ID proof along with latest copy of Telephone Bill.