CONSUMER APPLICATION FORM
(As per SCHEDULE – I, under sub-regulation (5) of regulation 3)
To be devised in Hindi, English, and the regional language of the area.
Part A: Consumer Information
| 1. Name: | |
| 2. Address: | |
| 3. Contact Numbers (Mobile/Landline): | |
| 4. E-mail (optional): | |
| 5. Aadhaar Number (Optional): |
Part B: Service Subscription related information
| 6. Details of service subscribed: | |
| (a) Name of a-la-carte pay channels/bouquets of pay channels and their distributor retail prices: | |
| (b) Bouquets of FTA channels: | |
| (c) Lock in period, if any: | |
| (d) Long term subscription, if any: | |
| Ins. by the Third Amendment Regulations, 2020, reg. 5 (w.e.f. 01.03.2020) | |
| (e) Number of TV connections in case of multi TV home: | |
| Ins. by the Third Amendment Regulations, 2020, reg. 5 (w.e.f. 01.03.2020) | |
| 7. Network capacity fee: | |
| (a) Network capacity fees declared based on different number of channels, regions, customer classes or any combination thereof: | |
| Subs. by the Fourth Amendment Regulations, 2024, reg. 14(a) (w.e.f. 06.10.2024) | |
| (c) For each additional TV connection beyond first TV connection in case of multi TV home: | |
| Ins. by the Third Amendment Regulations, 2020, reg. 6(d) (w.e.f. 01.03.2020) | |
| 8. Mode of payment (pre-paid or post paid): | |
| 9. Subscription amount to be paid (monthly/half yearly/yearly/etc.): | |
Part C: CPE related information
| 10. Scheme opted (Outright purchase/rental/other schemes): | |
| 11. Monthly rental for CPE if it is under rental scheme: | |
| 12. Refundable security deposit for CPE if any: | |
| 13. Retail price of CPE if it is under outright purchase scheme/other scheme: | |
| 14. VC number: | |
| 15. Type of set top box (MPEG2/MPEG4): | |
| 16. Guarantee/Warrantee/AMC details: |
(Note: Parts D, E, and F may be provided as a detachable acknowledgement receipt.)
Part D: Customer care centre related information
| 17. Customer Care Number: | |
| Subs. by the Fourth Amendment Regulations, 2024, reg. 14(b) (w.e.f. 06.10.2024) | |
| 19. Customer care centre e-mail: | |
Part E: Distributor of television channel/Local Cable Operator related information
| 20. Name of the distributor/LCO: | |
| 21. Address: | |
| 22. Contact numbers: | |
| 23. Website: | |
| 23(a) Restoration and Re-activation charges: | |
| 23(b) Visiting Charges: | |
| 23(c) Relocation charges: | |
| 23(d) MRP of the platform service channels: | |
| Ins. by the Fourth Amendment Regulations, 2024, reg. 14(c) (w.e.f. 06.10.2024) | |
Part F: Details of payment made
| 24. Total Amount paid: | |
| 25. Refundable security deposit, if applicable: | |
| 26. Monthly rental for CPE and period of rent if applicable: | |
| 27. Retail price of CPE in case of outright purchase scheme or other scheme: | |
| 28. Installation charges: | |
| 29. Activation fee: |