Registration Form
Personnel Information        
         
EXISTING CUSTOMER ? :
 
Yes No     
    (Yes, if account is dormant or blocked.)
CORPORATE / FIRM ? :
 
Yes No     
    (Yes, if applying for Corporate, Firm or Institution.)
CORPORATE / FIRM NAME:
 
   
TITLE :
 
Mr Mrs Miss
   
FIRST NAME:
 
   
LAST NAME:
 
   
FATHER NAME:
 
   
MOBILE PHONE:
 
 - 
   
COMPANY PHONE:
 
   
EMAIL ADDRESS:
 
   
CONNECTION DEVICE TYPE :
 
   
DEVICE MAC ADDRESS:
 
-----
  Please leave it blank or fill the actual MAC address.
   
   
Identity Information        
   
   

(Option 1)

 
   
CUSTOMER'S NIC #:
 
   

(If Aplicant/user is under age of 18 and NIC # has not been issued than option 2 applies)

(Option 2)

 
   
CUSTOMER'S "Form B" #:
 
   
PARENT / GUARDIAN NIC #:
 
   
PARENT / GUARDIAN NAME:
 
   

         
CITY/TOWN :
 
   
PHONE NUMBER:
 
* (Office/Residence Phone Number provide if available. Not Mandatory )
         

ADDRESS :

 
 

(Address where service/s
required)

 
       
PREFERRED LOGIN ID : 
 
* (Your Preffered Login ID )
         

Previous Information        
         
PREVIOUS LOGIN ID : 
 
 
PREVIOUS CITY/TOWN :
 
  (City Name of Previously Registered ID)
CONNECTION DEVICE TYPE :
 
   
DEVICE MAC ADDRESS:
 
-----
  Fill the actual MAC address of previous Device.
DATE OF SUBMISSION:
 
  Enter previous date
(Month and Year is Necessory)
DATE OF DISCONNECTION:
 
  (Month and Year of Disconnection)
 

By Clicking Submit you agree to all the Terms and Conditions elaborated on Terms page 
All fields marked with asterisks “*” are additional information and without filling those fields form will be acceptable