Government of India
            Ministry of Communications and Information Technology
                    Department of Information Technology
                         National Informatics Centre
                               Assam State Unit
                                   Guwahati                                   



                          NICNET Connectivity Form




1. Surname              :_______________________________________________

   First Name           :_______________________________________________

2. Designation          :_______________________________________________

3. Deptt./Org           :_______________________________________________

4. Office Address       :_______________________________________________
                         
                         _______________________________________________
 
5. Residential Address  :_______________________________________________

                         _______________________________________________

6. Telephone Number     :(Res) _________________________________________

                        :(Off) _________________________________________

7. Preferred Email Address      :__________________________@assam.nic.in

8. Whether the connectivity will be used from Residence/Office:





Date:  _______________                          (Signature of Applicant)
Place: _______________                              With Office Seal
_________________________________________________________________________

For Official use of NIC Assam State Unit 






                                              Approval of the Authority