APPLICATION FORM FOR INTERNET SERVICES - SLT.LK

1 APPLICATION form FOR INTERNET SERVICES To be filled by the customer 1. (a) Full Name of the customer / Company (b) NIC / Passport /BR No. 2. Billing Address 3. (a) Contact Phone No. (b) Fax No. (c) Email Address .. @ / <**> Pls note that the given email address should be an email only or an INTERNET Main acct of the customer. 4. Type of APPLICATION (a) New APPLICATION (b) Existing Customers Existing User name : .. Existing Package / Service : .. 5. Type of Service Domain Name : .. Hosting DNS Virtual Mail Service INTERNET /Email Package.

2 POP 3 Service Virtual Web Service Web Capacity : .. MB 6. Type of Access (a) Analog telephone line (b) ISDN Telephone line 7. For customers without SLTnet INTERNET or email account User Name Pass word OP-1 OP-2 * 14 characters Maximum * 8 characters and Maximum and 4 characters Minimum and 6 characters Minimum. (8). Do you require the software installation by SLT ? Yes No If yes the following charges should be paid with the APPLICATION . (Excluding Taxes) Pop 3 only : Rs. 8,000/= ; Proxy only : Rs. 4,000/= ; DNS only : Rs. 4,000/= POP3 + Proxy : Rs. 10,000/= ; POP3 + Proxy + DNS : Rs. 12,000/= I/ We do hereby declare that the information furnished by me/us are true and correct and agree to abide by terms & conditions that are presently enforced and those which will be enforced in future by Sri Lanka Telecom Limited.

3 Signature: 1.. 2.. Date : .. Note : 1. The applicant only should sign this form . 2. In the case of partnership, a partner or partners duly authorized by the partnership should sign and supported by a copy of the certificate of Business Registration. 3. In the case of registered companies either director or company secretary or any officer duly authorized should sign under the company common (embossed) seal. 4. Service will be provided to the applicant only. FOR OFFICIAL USE ONLY Payment detail of INTERNET Service Connection charges. Reference number : .. Amount Rs.: .. Receipt number : .. Date : .. Installation charges Amount paid : .. Receipt No.

4 : .. Date : .. May please provide DNS Hosting / POP 3 Service / Virtual Mail Service / Virtual Web Service / .. Authorizing Officer Date (affix official frank)