Hirani Telecommunication

Client Code(Subscriber code):

Receipt No:

First Name: *		Last Name: *

Tel (Home):

Tel (Office):

P.O.Box Address:

Mobile Number:

Road/Street:

Area:

Landmark:

Court/Building Name:

Block/House No:

Email: *

Please retype the Email for verification:

City:

Date Of Connection:

PLEASE TICK ON THE SERVICES REQUIRED:

Cable TV Terrrestial Internet

Notes:

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