BHARAT SANCHAR NIGAM LIMITED Subscriber Photo(As received from UIDAI)

(A Govt. of India Enterprise)

APPLICATION FORM FOR NEW MOBILE CONNECTION

USING e-KYC PROCESS
1. Mobile number allotted * 9416999169 1A. Persons with Disability (PWD) N

2. Unique Customer Application Form (CAF) No* BE56692209

3(a) Type of Connection* POSTPAID

4. Name of the Customer* Haseen Kumar

As received from UIDAI in case of individual/Outstation ;Name of company/entity/organisation incase of Bulk connection

5.Declaration/Consent by the POS agent * (In both English and Regional language) Subscriber Live Photo(Clicked by POS)

(I). I have intimated/informed the customer regarding the existing alternate process for acquiring the SIM viz.
Paper based Process and D-KYC process.
eSaus fle ÁkIr djus ds fy, e©twnk oSdfYid ÁfØ;k ds ckjs esa xzkgd d¨ lwfpr@lwfpr fd;k gSA isij vk/kkfjr ÁfØ;k vkSj Mh-dsokÃlh ÁfØ;k

(II). I hereby give my consent to use my Aadhaar number/ Virtual-ID and biometrics i.e. my finger(s) or iris by UIDAI for sharing the
eKYC details (demographic data and photograph) from my Aadhaar to the BSNL for the purpose of issuing SIM to the customer.

eSa ;wvkÃMh,vkà }kjk vius vk/kkj uacj@opqZvy-vkÃMh vkSj ck;¨esfVªDl ;kuh esjh maxyh ¼vksa½ dk mi;¨x djus ds fy, vius vk/kkj ls ÃdsokÃlh fooj.k
¼tulkaf[;dh; MsVk vkSj Q¨V¨½ d¨ ch,l,u,y d¨ fle tkjh djus ds mÌs'; ls lk>k djus ds fy, viuh lgefr nsrk gwa

5A. Unique response code (authorization) along with date & time stamp received from UIDAI in respect of POS agent*

Unique response Code* dedcdd840bd94e3ab35461a557c257fa Response Date and Time* 2025-01-03T14:38:36.521+05:30

6.Declaration/Consent by the Customer *(In both English and Regional language)

(I). I have been informed by the POS regarding the two existing alternate processes of acquiring SIM viz. Paper based process and D-KYC process.
eq>s ihvks,l }kjk fle ÁkIr djus ds fy, n¨ e©twnk oSdfYid ÁfØ;kvksa ds ckjs esa lwfpr fd;k x;k gSA isij vk/kkfjr ÁfØ;k vkSj Mh-dsokÃlh ÁfØ;kA
(II). I am voluntarily using Aadhaar based e-KYC process for acquiring the SIM.
eSa LosPNk ls fle ÁkIr djus ds fy, vk/kkj vk/kkfjr Ã-dsokÃlh ÁfØ;k dk mi;¨x dj jgk gwaA
(III). I hereby give my consent to use my Aadhaar number/Virtual-ID by UIDAI for sharing the eKYC details (demographic data and photograph) from my
Aadhaar to the BSNL for issuing of mobile connection to me.
eq>s e¨ckby dusD'ku tkjh djus ds fy, esjs vk/kkj ls ch,l,u,y d¨ ÃdsokÃlh fooj.k tulkaf[;dh; MsVk vkSj Q¨V¨½ lk>k djus ds fy, ;wvkÃMh,vkà }kjk vius vk/kkj uacj@opqZvy-
vkÃMh dk mi;¨x djus ds fy, viuh lgefr nsrk gwaA

6A. Unique response code (authorization) along with date & time stamp received from UIDAI in respect of customer*

Unique response Code* 6a6ca94ad45f400da20b63ee8a0c8383 Response Date and Time* 2025-01-03T14:37:04.790+05:30

7. Name of Father/Husband* S/O: Gurbhaks Singh
8. Gender* (As received from UIDAI) MALE 9. Date of Birth*(As received from UIDAI)(DD/MM/YYYY) 09/03/1978
10. Status of Customer* INDIVIDUAL
11. Complete local residential address of Customer* (As received from UIDAI): (For Individual customer only)(Only those fields are mandatory as received from UIDAI)

(C/o)/(D/o)/(S/o)/(W/o)/(H/o) Gurbhaks Singh

House No/Flat No H N0- 839
Street Address/Village sector 13
Locality/Tehsil URBAN ESTATE State/UT HARYANA
City/District Thanesar Kurukshetra Pincode 136118
11D. Complete permanent residential address of Customer* (As received from UIDAI): (For outstation customer only)(Only those fields are mandatory as received from UIDAI)

(C/o)/(D/o)/(S/o)/(W/o)/(H/o) Gurbhaks Singh

House No/Flat No H N0- 839
Street Address/Village sector 13
Locality/Tehsil URBAN ESTATE State/UT HARYANA
City/District Thanesar Kurukshetra Pincode 136118
11E. Complete local residential address of Custome. i.e. the address within the service area) (For outstation customer only)

(C/o)/(D/o)/(S/o)/(W/o)/(H/o)
House No/Flat No/Building/Apartment
Street Address/Road name Landmark
Area/Sector/Locality * State/UT *
Village/Town/City Pincode *
District *
12. Nationality* Indian

13. Number of Mobile connections held in name of Individual/Outstation

customer(Includlng all TSPs)* 0

15. Tariff Plan Applied* PLAN 199 16. Value Added Services Applied(if any)

17. E-mail address (if any) 18. Alternate Contact numbers(if any) 8278411114

19. Profession of Subscriber OTHERS 20. PAN/GIR

21. Details (Name, address and phone number) of Local reference*(For Outstation customer)

a. Name ___________ c. Phone number

b. Address

d. Local reference number OTP value * e. OTP validation Date and Time *

22. To be filled in cases of Mobile Number Portability (MNP ) 22A. UPC

22B. Previous Service Provider & Licensed Service Area Details

23. To be filled in cases of Post-paid connections

23A. Form of Payment: Cash Cheque Credit card Debit card

23B. If payment made by cash/cheque/creditcard/debitcard

a. Bank A/c No b. Bank Name

c. Branch Name & Address ,

24.Declaration/Consent by the Customer * (In both English and Regional language)

(a).The information provided by me to the POS agent in my respect is correct.

esjs }kjk ihvks,l ,tsaV d¨ esjs laca/k esa Ánku dh xà tkudkjh lgh gSA
(b). My biometric authentication can be treated as my signature.
esjs ck;¨esfVªd Áek.khdj.k d¨ esjs gLrk{kj ds :i esa ekuk tk ldrk gSA
(d). I have received 1(one) no. of SIM Cards. (Shall always be one in case of individual/outstation Customer)

eq>s 1¼,d½ uacj ÁkIr gqvk gSA fle dkM¨± dhA ¼O;fäxr@ckgjh xzkgd ds ekeys esa ges'kk ,d jgsxk½
(e). I hereby give my consent to use my Aadhaar number/ Virtual-ID and biometrics i.e. my finger(s) or iris by UIDAI for the above (a to d) declaration.
eSa mij¨ä ¿a ls d½ Ĩ"k.kk ds fy, vius vk/kkj uacj@opqZvy-vkÃMh vkSj ck;¨esfVªDl ;kuh esjhmaxyh ;k vkÃfjl gkà ;wvkÃMh,vkà dk mi;¨x
djus ds fy, viuh lgefr nsrk gwaA

24A. Unique response code (authorization) along with date & time stamp received from UIDAI in respect of customer*

Unique response Code* 6a6ca94ad45f400da20b63ee8a0c8383 Response Date and Time* 2025-01-03T14:37:04.790+05:30

Fields to be filled by Service Provider/Authorized representative

25. IMSI No. 404344400619833 (For Individual / Outstation customer only)

26. Point of Sale Code* HR06403000 27. Point of Sale Name* CSC KURUKSHETRA

(To be populated by Licensee) (To be populated by Licensee)

28. Point of sale agent name (As received from UIDAI)* Mohinder Singh
29. Complete Address of Point of Sale* (To be populated by Licensee)

House No/Flat No/Building/Apartment/(C/o)* 000

Street Address/Road name /Wad No * CSC New Telephone exchange Sector 13

Land Mark Area/Sector/Locality * Kurukshetra

Village /Town/ City * Kurukshetra District * Kurukshetra

State/UT* HARYANA Pincode* 136118

31.Declaration/Consent by the POS agent * (in both english and regional language)
(a). I have captured the Live photograph of the customer.
eSaus xzkgd dh ykbo Q¨V¨ [kÈph gSA
(b). I certify that Subscriber Identification Module (SIM) has been handed over to the Haseen Kumar only.
eSa çekf.kr djrk gwa fd lClØkbcj vkbMsafVfQds'ku e‚Mîwy ¼fle½ dsoy Haseen Kumar dks lkSai fn;k x;k gSA
(c). I have tele-verified the local reference i.e. Mr/Ms/Mrs ___________ on his/her telephone number (wireless or wireline) _____________ by my telephone
number (wireless or wireline) ___________ . (for outstation customers)

eSaus xzkgd ds LFkkuh; laidZ dks vius VsyhQksu uacj }kjk ¼ok;jysl ;k ok;jykbu½ _____________ ij LFkkuh; lanHkZ vFkkZr Jh@lqJh@Jherh
___________ Vsyh lR;kiu fd;k gSA ¼ok;jysl ;k ok;jykbu½ ___________
¼vkmVLVs'ku xzkgdksa ds fy,½
(d).My biometric authentication can be treated as my signature.
esjs ck;¨esfVªd Áek.khdj.k d¨ esjs gLrk{kj ds :i esa ekuk tk ldrk gSA
(e).I hereby give my consent to use my Aadhaar number/ Virtual-ID and biometrics i.e. my finger(s) or iris by UIDAI for the above (a to d) declaration.

eSa vius vkèkkj uacj@opZqvy-vkbZMh vkSj ck;ksesfVªDl ;kuh esjh maxfy;ksa ;k vkbZfjl gkbZ ;wvkbZMh,vkbZ@;k mijksä ¼, ls Mh½ ?kks"k.kk dk mi;ksx djus ds fy, viuh lgefr nsrk gwa
31A. Unique response code (authorization) along with date & time stamp received from UIDAI in respect of POS agent*

Unique response Code* dedcdd840bd94e3ab35461a557c257fa Response Date and Time* 2025-01-03T14:38:36.521+05:30

32. Unique acknowledgement receipt number given by Licensee to customer (To be populated by Licensee)* BE56692209

Fields to be filled by Service Providers before SIM activation

33. Details of Add-on/Value Added facilities (like Internet, 3G, Call transfer facility. ISD facility, GPRS, navigation, Tariff plan etc.) activated on the SIM Card

STD,National Roaming,Itemized Billing,3G

34. Declaration by the authorized representative or the IT-system of the Licensee before activation of SIM card
a) All the entries in the CAF & Licensee's database for the respective customer are complete and there is no error apparent on the face of records of
the customer in the CAF & database.
b) Live photograph of the customer matches with the photo received from the Aadhaar/ UIDAI.
c) All of the necessary details in CAF including mandatory fields are filled properly.

d) No Gibberish information is stored in the CAF and Licensee's database.

34A.SIM activation*:-Manually

34B. Name & designation of the authorized representative of the Licensee or the IT- system activating the SIM on behalf of the licensee*

Raj Verma(77725940 ) (XPLORETECH-CA ) e-KYC

35.SIM activation Date*: 03-JAN-2025

35A.SIM activation Time*: 02:42:44 PM

Note: The above mentioned Date and Time as as per BSNL CSC approval

Digital Signature of authorized representative of Licensee who is activating the SIM*

Signature Not Verified

Digitally signed by DS BHARAT
SANCHAR NIGAM LIMITED 03
Date: 2025.01.03 15:04:51 IST
Reason: EKYC CAF Approval
Location: India