CUSTOMER CONNECTION AGREEMENT FORM - Airtel Africa

CUSTOMER CONNECTION AGREEMENT FORMAirtel Networks Limited,Plot L2, Banana Island,Ikoyi, Lagos.Tel: +234 (0) 802 1901 500, +234 (0) 802 190 1501Fax: +234 (0) 802 190 1503www.ng.airtel.comCHANNEL NAME_______________________________________________________CREDIT CONTROL REFERENCE____________________________________________CHANNEL CODE___________________________________SUBSCRIBER ACCOUNT NO__________________________PACKAGE CHOSEN_____________________________________________________ CORPORATE INDIVIDUALCUSTOMER DETAILSINDIVIDUALCORPORATEMr. / Mrs./Ms.________________________________________________First Name Other Names SurnameCompany Trading Name (if any) __________________________________Business Type ________________________________________________Office Number________________________________________________E-mail Address _______________________________________________Fully Registered Company Name (Inc. Registered Societies, _____________________churches etc) ___________________________________________________________Names of Designated Officer_______________________________________________Business Type____________________________________________________________Phone Numbers__________________________________________________________E-mail Address __________________________________________________________Residential AddressHouse Number_______________________________________________Street Address_______________________________________________Nearest Landmark____________________________________________Area/LGA___________________________________________________Town _______________________________________________________State_______________________________________________________Company AddressBuilding Name (if any) ____________________________________________________House No/ Street Name ___________________________________________________Nearest Landmark________________________________________________________Area /LGA _______________________________________________________________Town___________________________________________________________________State___________________________________________________________________

SERVICE REQUIREDItemized Billing IDD Services Directory ListingDETAILS OF PERSON USING THE PHONE (If different from above, please tick)Mr./Mrs./Ms.First Name Other Names SurnameHome Address__________________________________________________Home Address__________________________________________________Current Phone Number___________________________________Current Phone Number___________________________________DECLARATIONI/ We hereby certify that all the information provided is correct. I/ We authorize Airtel to use the information therein to process the application forNetwork Services. I/ We hereby acknowledge upon acceptance for Network Services by Airtel, a contract will commence. I/ We confirm that wehave been provided with a copy of the Terms and Conditions and have read and understood the same.Name Authorized Signature_______________________ Date___________________Mobile Telephone NumberACTIVATION REQUESTl NuSerial NumberSe NameAuthorized Signature___________________________________________Date_______________________________