BHARAT SANCHAR NIGAM LIMITED
(A Govt. of India Enterprise)
APPLICATION FORM FOR NEW MOBILE CONNECTION (D-KYC Process)
www.bsnl.co.in | Help line : 1800 180 1503
Unique Customer Application Form (CAF) No* BD74452503
Type of Connection* PREPAID
1. Name of the Subscriber* SHUBHENDRA KUMAR YADAV
1A. Persons with Disability (PWD) No
2. Name of Father/Husband* SHIV BHAGVAN
3. Gender*: MALE 4. Date of Birth* 08/10/2003
5. Complete Local Residential Address*:
(C/o)/(D/o)/(S/o)/(W/o)/(H/o):
House No/Flat No/Building/Apartment*: 54
Street Address/Road Name*: haraiya harraiya sitapur
Landmark: Area/Sector/Locality*: harraiya sitapur
Village/Town/City*: sitapur District*: Sitapur
State/UT*: UTTAR PRADESH Pin Code* - 261301
6. Complete permanent residential Address of subscriber*:
(C/o)/(D/o)/(S/o)/(W/o)/(H/o):
House No/Flat No/Building/Apartment*: 54
Street Address/Road Name*: haraiya harraiya sitapur
Landmark: Area/Sector/Locality*: harraiya sitapur
Village/Town/City*: sitapur District*: Sitapur
State/UT*: UTTAR PRADESH Pin Code* - 261301
7. Status of Subscriber*: INDIVIDUAL 8. Nationality* Indian
9. Photo ID Proof type * (As per prescribed list of valid PoI documents): 10.Address proof document type* (As per prescribed list of valid PoA documents):
Type of POI Unique Identification Authority of India (12Digts) Type of POA Unique Identification Authority of India(12Digits)
Document No.* 943571694472 Document No.* 943571694472
Date of Issue 01/01/1900 Date of Issue 01/01/1900
Place of issue Bengaluru Place of issue Bengaluru
Issuing Authority* UIDAI Government of India (GOI) Issuing Authority* UIDAI Government of India (GOI)
11. Number of Mobile connections held in name of Applicant (Operator-wise)*-
12. Tariff Plan Applied*- NORMAL BASIC PREPAID
13. Value Added Services Applied (if any)
14. E-mail address (if any):
15. Alternate Contact numbers, if any: Home: Business Mobile 7266925645
16. Profession of Subscriber: 17. PAN/GIR:
18. Details (Name, Address and phone number) of Local reference*(Outstation customer):
Name phone number
Address
19. To be filled in cases of Mobile Number Portability (MNP )
(A) UPC
(B) Previous Service Provider & Licensed Service Area Details:
20. To be filled in cases of Post-paid connections
(A) Form of Payment Cash Cheque Credit card Debit card
(B) If payment made by cash/cheque/credit card/debit card
a. Bank A/c No b. Bank Name
c. Branch Name & Address
21. Mobile Number Used For Customer Signature *: 7266925645
Self: Family member/Relative: Known person:
CUSTOMER OTP*: 645016 OTP VALIDATION DATE & TIME*: 21/12/2021 06:57:39 PM
Latitude longitude details: 26.9522984,80.9294896 as per customer photo
Fields to be captured/entered by Service Provider/Authorized representative
22. IMSI No.* 404557240705177 23. Mobile Number allotted* 8765389350
UELKORET1600923 25. Point of Sale Name *: MAHENDRAKUMAR
24. Point of Sale (PoS) code*
26. Complete Address of Point of Sale* (To be populated by Licensee) {valid up to 31.12.2019}:
House No/Flat No/Building/Apartment:
Street Address/Road Name:
Landmark: Area/Sector/Locality:
Village/Town/City: District:
State/UT*: Pin Code -
26A. Complete Address of Point of Sale* (To be populated by Licensee) {valid w.e.f.01.01.2020}
House No/Flat No/Building/Apartment/C/o*: Lekhraj gold
Street Address/Road Name/Ward No *: ring road Lucknow
Landmark: Area/Sector/Locality*: Indira nagar
Village/Town/City*: Lucknow District*: Lucknow
State/UT*: UTTAR PRADESH Pin Code* - 226016
27. Name of local reference contacted by PoS at time of Sale* (in case of outstation customer):
28. DECLARATION BY PoS*:
a. I have seen the customer and also taken/captured a live photograph of customer and his/her original documents.
b. I have not used my registered mobile number or any of my numbers for getting the OTP in Customer Signature.
c. OTP received on my registered number 9452004606 on 21/12/2021:18/52/48 and verified on
21/12/2021:18/57/18 shall be treated as my signature & the photograph captured on this CAF is my live photograph.
d. I confirm that I have not saved the customer photograph & PoI/PoA document photograph during this process.
e. I have issued the SIM card and handed over the same to the customer.
PoS Registered Mobile Number*: 9452004606
PoS OTP*: 244529
Latitude longitude details: 26.9522958,80.9294912
29. Declaration by Activation Officer (AO)/Authorized Representative (AR) of Licensee*:
a) Information available in the pictures of PoI/PoA documents is matching with the information entered by PoS in CAF.
b) Live photograph of the customer matches with the photo available in the PoI/PoA documents.
c) All of the necessary details in CAF including mandatory fields are filled properly.
d) In case of outstation subscriber, tele-verification of local referee has been done either by tele-calling or OTP based authentication
(as mentioned in para 3 of instructions dated 03.04.2019). {OTP sent on Local Reference number on
and verified on )}
Format of Digital Signature of Activation Officer(AO)/Authorized Representative(AR) of Licensee *
AO/AR Code/*: UELKOCSC15
Name of AO/AR*: RAVINDRA NATH(199306942 )
Designation of AO/AR*: TT
Signature Not Verified
Digitally signed by DS BHARAT
SANCHAR NIGAM LIMITED 02
Date: 2021.12.22 11:47:26 IST
Reason: DKYC CAF Approval
Location: India
