application form

Welcome to Etisalat. Complete this form if you are applying for eLife Bundled services.

eLife
Serial No.:

Personal details
*Name of applicant Mr./Mrs./Ms.: C/O: *Mobile (1): *ID Type: Location Building: Area: Sector:
*Mandatory

*P. O. Box: Mobile (2): *ID No.: Floor: City: Plot:

*Emirate: *Email: Expiry:

Date/month/year

*Nationality:

Flat No.: *Working landline number in the same building:

Etisalat EID (located on ground oor entrance):

1. Service Bundles & options

Please select one () Double Play (Broadband+Landline) Triple Play (Broadband+Landline+TV)
Max 30 3 Premier Master 16 1 Unlimited** Antivirus + eSupport Services included
5 emails 5 emails 5GB 5GB 5 emails 5 emails 3 emails 3GB 2GB 500MB 1 email 250MB 1 email 250MB

3. Phone value-added services

Code Call Barring (International) Provide a PIN Call Forwarding on Busy Call Forwarding (Unconditional) Call Forwarding on No Reply Do Not Disturb Call Waiting List name in phone directory Additional socket activations Code Call Barring (National) Star Package (Call Waiting, Conference and Forwarding) Advanced Star Package (Call Waiting, Conference, Forwarding, Call Barring and Caller ID) Additional phone line

Bundles
Download Mbps Upload Mbps

300/100

Entry 1 0.250

Starter 1 0.250 6GB**

Lite 0.512 0.128 1GB**

300/100 30/10

8 1

Data limit (per month)

8 Hrs hotspot
Phone services included Add-ons included
IDD Calls at Local calls + Caller ID (CLIP) + Voicemail 99 ls/min + 20 minutes of international calls*

Hotspot Not applicable Local calls Adds-ons Not applicable

4. Broadband username
1st choice 3rd choice 2nd choice 12 installments On loan

8 An Extra 2nd and Extra Hrs Basic TV landline hotspot

Extra 8 Hrs hotspot

5. Devices
Router/Gateway TV Set-top-box Remote control Wi-Fi Extenders Other:

Purchase

Have own

** For Starter and Lite, data overusage is charged at AED 25 per GB. Unlimited packages are subject to fair use policy * Based on prior months IDD average charges

2. TV
Note: (Please select one or more)

TV Box Type: Zapper

Arabic OSN e-Firstnet
Asian

Recorder (PVR)
Western Filipino

Choice Basic TV

Family Platinum Basic Basic TFC

AD Sports My Pinoy Pehla Variety

Movies Pinoy Plus Premium Silver

Premier Plus Pinoy West

Premium TV

Language English Arabic Format 1. e-Bill 2. Mail 3. One Bill for Multi-account 4. No. Bill Detailed Detailed Account 1 Summary Summary Account 2 Address/email:
The applicant agrees to the Terms and Conditions of Etisalat and acknowledges that eLife is subject to a 12-month contract. The contract may be terminated during the contract on payment of the value of any promotional savings received. The applicant has authority and gives permission to install the service at the address provided.

6. Bill statement

e-Pehla ART
Al Jazeera Sports

Gold

7. Your authorisation

High TV 3D eLife Family Russian Package

ART Mini GMA News eLife Lifestyle

Popular a la carte

Zee Family HD eLife Arabia

Signature:

Date:

Other a la carte:

Extra TVs

Quantity

(Max 3 TVs)

8. Required documents

For ofcial use only

Sales Person Name:
Dec. 2012

UAE National: Valid passport copy or any other positive identication GCC National: Valid passport copy or any proof of stay in the UAE Expatriates: Valid visa and passport copy

Salesman Code: Reseller Code:

Contact No.:

S/R No.: Remarks: