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Etisalat Service Request Form

This document contains a customer's application for telecommunication services from Etisalat in the United Arab Emirates. It includes the customer's personal details like name, ID information, contact details. It also includes the requested services, device details, billing information, additional notes, and signatures from the customer and Etisalat representative authorizing the new account.

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med
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111 views1 page

Etisalat Service Request Form

This document contains a customer's application for telecommunication services from Etisalat in the United Arab Emirates. It includes the customer's personal details like name, ID information, contact details. It also includes the requested services, device details, billing information, additional notes, and signatures from the customer and Etisalat representative authorizing the new account.

Uploaded by

med
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Contact No : Date :

Name of applicant Mr./Mrs./Ms

P.O Box : 0 Emirate: Abu Dhabi Na onality :

ID Type : UAE iden ty Card

ID Document No : Date of Issuance: Date of Expirty :

Visa No : Date of Issuance: Date of Expirty :

Date of Birth : Gander : Male Working No :

I would like to receive SMS updates about Etisalat's promotion and offers :NO

Email :

Account Number :
Request Type :
1.Service Information

Service Information Rental Perpayment

Special roming service 12 0

2. Device Details

SIC Code Description IMEI S/N

3. Bill Information

Bill cycle Address Line 1 Address Line 2 PO Box Email (Bill to be sent on) PO Box (Bill to be sent on)

4. Additional Info

PRICE :

5. Your authorization

Terms and conditions Agreed

Customer Signature Company Retail Employee signature

For official only

New Account No: Code Store Code Sales Staff : Igreham


Request No: Sub Request : Party ID : Authorized mangement

UNITED ARAB EMIRATES ETISALAT


Etisalat Building, Sheikh Rashid Bin Saeed Al Maktoum Street P.O. Box 3838, Abu Dhabi,
UAE
Tel: 97126283333, Fax: 97126317000
www.etisalat.ae

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