Customer Registration Form (Broadband Internet)
for All
(Fields with
*
are must required)
Full Name
*
Mobile No.
*
Email Address
*
NID
(Optional)
District
*
select
ID
NAME
Upazila/Thana
*
select
ID
NAME
Address
*
Connection For
*
select
ID
NAME
Package
*
select
ID
NAME
1
MINOR+ 12 Mbps for Home
2
JUNIOR+ 20 Mbps for Home
3
LEARNER+ 35 Mbps for Home
4
BASIC+ 45 Mbps for Home
5
PRIMARY+ 55 Mbps for Home
6
DOMINANT+ 65 Mbps for Home
7
CONFIDENT+ 80 Mbps for Home
8
POSITIVE+ 100 Mbps for Home
9
SME PRO 30 Mbps for SME
10
SME ULTRA 40 Mbps for SME
11
SME MAX 50 Mbps for SME
!
MRC
OTC
Service Charge
Sub-Total
Discount (OTC)
Discount (MRC)
MRC Vat
Net MRC
OTC Vat
Net OTC
Total Net Payable
Verification Code
Code
*
I agreed with the
terms and conditions
billGENIX FeedBack