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AG COMMUNICATION
Customer Information Form (Demand On BTRC)
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* Indicates required question
Name:
*
Your answer
Fathers Name:
*
Your answer
Mothers Name
Your answer
Present Address (House No)
*
Only House No. (No others Character)
Your answer
Present Address (Floor/Flat No)
*
Only House No. (No others Character)
Your answer
Present Address (Road No)
if any
Your answer
Present Address (Area)
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Female
Male
Prefer not to say
Other:
E-mail Address:
*
Your answer
Mobile No:
*
Your answer
Internet Connection Date:
MM
/
DD
/
YYYY
Bandwidth:
*
Only Numeric Character (Not Mbps)
Your answer
Billing Amount (Excluding Vat):
*
Only Numeric Character (Not TK)
Your answer
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