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    Adobe Scan 12 Feb 2024

    Uploaded by

    Leo John

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Adobe Scan 12 Feb 2024

    Uploaded by

    Leo John
    4 views1 page

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4 views1 page

    Adobe Scan 12 Feb 2024

    Uploaded by

    Leo John

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    .

    I
    Change Request Form Fontno. I ·CRQOOOQ2RM74
    fllel ; rd,-... ._ Alllrd..10 lrlooo.11n lmled,
    PFIDII: ...,_a- ,-.N. 222. NlnlwaPart, ~4000 21 •
    ,-022 220" 2288 .!)aN :~12
    Jio .
    '.
    '
    Pleme paste a recent passport
    size oolcU photograph of the
    customer.

    Reguest DelaiJs
    Do not staple.
    OCorpa ete

    Postpaid
    CUSTOMER
    SIM Repllame nt Relocation Visa Extension TO SIGN ACROSS

    D0ttssNOl S:ener
    , PHOTOGRAPH & FOAM
    t:)

    (l<idy • n Capllal Letters)


    Customer Cnronnation
    Mobile/ FT1X tvnber'"
    18,5 4,7,3, 3615,341
    I Con1)8ny name•
    IC ,H, I, Ti R, A, Iv, ,R,
    Circle / State·
    Ik', E, R, A, L, 8, , , I I I I
    (l<ilctz' enclose proof c:A new adaessl
    0 O Office O Permanent O Shifting Send my bl at O Local O Office
    Addrw Change Details Local

    QmrnAd dress
    -J...-L.--L-..L..I....J,__,__ _ _.._____.___.__...,___.~I
    LI ...LJL.L....L_L-1._l_.J....-1---1.........l..-.JL..L....1.,_l..-J.---1........L...J---L...J
    L-.I...~~---'
    ....J.~-'--1-~-'--1-~~-----'~~1
    ~I-L-J.-L--L-J.-L--L-J.--L-.L
    NewAdctess
    I I I I ,., I

    Visa Exta .siai, Detals


    Type of visa
    Passport rurber

    Visarunber
    v~ expiry date

    Moble Change Details


    New Registered Mobile No.
    Qmrn Registered Mobile No.
    I I I I I I I I I •
    I I I I I I I I
    SIM Replacem n Request 0 Damaged O Lost (for lost SIM il JK circle, AR copy is mandatory) 0 Upgrade
    Fill details or Paste sticker"
    Qmint SIM No. (If available)
    I I I I I I I I ,· I I I I I I I I I
    _-----== ----~ hereby confirm that I have been
    I, _ _ _ _ _ _ _ _ son of/ daughter of _ _ roono.
    verified O my prepaid calls and recharges done recently
    using the mobie runber _ _ _ _ _ _ _ _. I have
    0 my Postpaid bl a,d agree to pay the !a1l8 by dJe date. I am also providing my POVPOA to Reliance and authorise
    Relicn:e to take legal action in case the issued SIM is involved in arry
    fraudulent activity.
    IMSI no. I BLtilg ID
    - - - - - - - - - Date: _ _ _ _.
    Name and siglalu'e of customer (as per P O ~ - - - -

    Kildly attach document matching proof of identity Proof of Addl'9SS (POA) Mandatory for relocatior ,. sn1'ti'lg or cha,ge i1 Address ort,J
    Proof Of Cdlnllly tpOQ-
    Typeof POA
    Type of POI
    L...I_ _ _ _.....I 'ssued by
    Document no.
    Downent no. f j Pla::e o! issue ....f _ _ _ ____,
    Date of issue
    f vjvJvf vf
    Date of Issue

    CUatonw Declaidiort Point of Sale (POS) Declaration


    and certify that the
    IM'e further dedare and Lfldertake that al the information provided by
    me/us is true and ltNe hereby undertake and confirm that Wle have seen the customer
    the self-attested _
    conect in al aspects. - original proof of identity and adcress has been matched and verified with
    documents submitted by the customer.

    C_ustomer / Authorised Signatory POS

    In 0819 o( OOll'll)lf,y.
    NM18 of Authorised Signatory:
    c~ . ...
    Agent Name: L EO
    of Authorised SVlatory: Agent Code: &o "2 5 I G 3
    Date of decimation
    Slgnatura & Stamp Date°' deda-atoo 12. I©12-141 SViatue&S 1anl)wtth
    P0S oode & adctess

    Acllwdion 0fflcer Declaration ===== ===:


    :_-_:_ -_:_:_ -:::::_- _:_:_: _-:::::: ::_-_:_ :_-_:-= =====
    -------- -----~: ::_-_:_ -_:_:_ -_:_-_ :_-_:_ :_:_-_ :_-_-_
    Activation Offic er
    matching with the racords avaiable in c::Jaht>ase.

    Ollloer Nmne:
    :Svia tue~ &stanl) al Actlvallan Officer
    Ollloer Oode: _---!l=o~'=D~'~'=M='M~'-='y~'y~'y~'== y='--- ------=
    decwation
    1-Date_of__

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