Government of the Peoples Republic of Bangladesh

Bangladesh Telegraph and Telephone Board

LEASED LINE INTERNET ACCESS FORM

Please read the following note before filling out this form

Note:. By completing this form and submitting it to us, you are agreeing to be bound by the terms and conditions set forth in the Internet Leased Line Access Agreement. You must have to submit the following papers along with the filled up Application Form

Network Diagram

Attested 2 copies of Passport Size Photograph (for private applicant).

Related supporting documents if the account is eligible for discount

Registrant Information:
Registrant Name	:
Address	:
City	:
State/Province(if applicable)	:
Postal Code	:
Email	:
Phone	:
Fax	:
Registrant Category	:	1 Educational. 1 Government 1 Industrial 1 ISP 1 International Org 1 Foreign Org: 1 Others.
Registrant Status	:	1 Government. 1 Autonomous 1 Private. 1 Others.
Connection Type	:	1 Permanent 1 Temporary. 1 Others.
Account Eligible for Discount	:	1 Yes. 1 No.
Contact Information:
A) Administrative Contact Information:
Full Name	:
Title/Occupation	:
Organization (if applicable)	:
Address	:
City	:
Postal Code	:
Email Address	:
Phone	:
Fax	:
Signature	:		Date:
B) Technical Contact Information:

If this information is the same as the Administrative Contact information, you may keep it blank.

Otherwise, please complete this section with the appropriate information.

Full Name	:
Title/Occupation	:
Organization (if applicable)	:
Address	:
City	:
Postal Code	:
Email	:
Phone	:
Fax	:
Signature	:	Date:

Technical Information:
Desired Speed of connection	:	Kbps
IP Address to be procured from BTTB	:	1 Yes 1 No
Desired required Number of Hosts: (Only required if IP Addresses are to be procured from BTTB)	:

FOR OFFICIAL USE ONLY

Registration Information:
Registration Number	:
Date	:
Signature of Authorized Personnel	:	Date

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