Registration Form – ASTL Communication

Registration Form

Personal Information / ব্যক্তিগত তথ্য

Date:

Upload Photo:*

Customer Name:*

Father's Name:*

Mother's Name:

Gender:

Date of Birth:

Occupation/পেশা:

NID/Birth Reg No:*

NID/Birth Reg Photo:

Reference:

Remarks/Special Note:

Contact Information / যোগাযোগের তথ্য

Mobile Number:*

Alternative Mobile:*

Email Address:

District: *

Upazilla: *

Word No: *

Road Name/No:*

House No:*

Network & Product Information

Connection Type:*

Connection Man Name:*

Connection Man Photo:*

Service Charge:* (Non-Refundable)

Package:*

Monthly Bill:*

Cable Length:

Onu/Router Name:

Joining Date:

Billing Date :

Client Type: