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Page 1 of 3 Bangladesh Telecommunication Regulatory Commission IEB Bhaban, Ramna, Dhaka-1000 Application Form for Internet Service Provider including Cyber Cafe License (For Internet Communication excluding Voice Communication) [See Section 36(5) of the Bangladesh Telecommunication Act, 2001] [Please see the General Information and Guidelines] □ NEW □ RENEWAL [Incomplete application will not be entertained and summarily rejected] A. Applicant Profile 7 1. Name of Entity: Registered Office Address Telephone & Mobile Fax E-mail Website 2. Name of Contact Person: Full Address for Communication Telephone & Mobile Fax E-mail Website 3. Category of License: [ ] Category A [ ] Category B [ ] Category C (i) Coverage Area : ( Police Station(s) and Metropolitan area/District Name Only ) B. Service Profile (Applicable for Renewal) 7 1. Location of Installation(s) : 2. Date of Commencement of the Service: _______ / _______ /__________ Day Month Year 3. Application for the period: _______ / _______ /__________ To _______ / _______ /__________ Day Month Year Day Month Year Page 2 of 3 4. Number & date of License of which renewal is sought for: License Number & Date : 5. a. Number of Clients/Users of Internet: Home: Office/Corporate User : Cyber Café: Others : C. Technical Profile : 7 1. Type of Service: [ ] Wired (Optical/Copper) (i). Wired Length of laid cable : Km. □ Optical Fiber □ Copper (ii) Bandwidth: [ ] Sublease Provider : Allocation : Up - Down - Medium : Backup : Allocation : Up - Down - Medium : D. Pay Order/Bank Draft Details 7 Type of Payment: [ ] P.O. [ ] D.D. (i). Name of Bank : (ii). No. : (iii). Date : E. Documents to be Enclosed: 7 (i) For new License (License for providing ISP including Cyber Cafe Services): [ Use tick [√] mark in the appropriate box Serial Items Attached Not Attached Remarks 1. Application in a Letter Head Pad 2. Relevant Fees in the form of Pay Order/Bank Draft 3. Agreement with the bandwidth provider (National/Zonal ISP) 4. House-Rent Agreement/Ownership deed. 5. Bank Solvency Certificate 6. Undertaking about not as a Bank Defaulter 7. Certificate of Incorporation ( if applicable ) 8. Memorandum & Articles of Association ( if applicable ) 9. Trade License 10. Proposed Tariff Chart 11. Undertaking on non judicial stamp of Tk. 150/- sworn before the notary public of Bangladesh about not to take any activity over VOIP / WiMAX business. 12. Latest Income Tax Clearance Certificate (if applicable) (ii) For Renewal of License (License for providing ISP including Cyber Cafe Services): Use tick [√] mark in the appropriate box Serial Items Attached Not Attached Remarks 1. Application in a Letter Head Pad 2. Relevant Fees in the form of Pay Order/Bank Draft 3. Statement of Payment to the Bandwidth Provider Page 3 of 3 4. Trade License ( updated ) 5. Expanded Network Diagram in details 6. Tariff Chart ( approved by the commission ) 7. Latest Income Tax Clearance Certificate 8. Bank Solvency Certificate 9. Undertaking on non judicial stamp of Tk. 150/- sworn before the notary public of Bangladesh about not to take any activity over VOIP / WiMAX business. C. Declaration : 7 1. Has any Application for License of ISP been rejected before? □ Yes □ No (if yes, please give date of application and reasons for rejection) 2. Has any License issued previously to the Applicant/any Share Holder/Partner been cancelled? □ Yes □ No (if yes, give details) 3. Do the Applicant/any Share Holder/Partner hold any other Operator Licenses from the Commission? □ Yes □ No (if yes, give details) 4. I/We hereby certify that I/We have carefully read the guidelines/terms and conditions, for the license and I/We undertake to comply with the terms and conditions therein. 5. I/We hereby certify that I/We have carefully read the section 36 of Bangladesh Telecommunication Act, 2001 and I/We are not disqualified from obtaining the license. 6. I/We understand that if at any time any information furnished for obtaining the license is found incorrect then the license if granted on the basis of such application shall deemed to be cancelled and shall be liable for action as per Bangladesh Telecommunication Act, 2001. Date: Signature Place: Name of the Applicant/Authorized Signatory with Seal Information Category of License for Providing ISP including Cyber Cafe Services Information 7 1. Category A: For each Police Station (P/S) of Dhaka Metropolitan Area. 2. Category B: For each Police Station (P/S) of Chittagong, Rajshahi, Khulna, Sylhet and Barisal Metropolitan Area. 3. Category C: For each Police Station (P/S) of other than Metropolitan Area. Note: No application for renewal of license shall be entertained beyond 90 days of the expiry of the year of license concerned and the license shall then stand cancelled and penal action shall follow if the licensee continues his business thereafter without valid license. The charges/fees/fines upto 90 days if not paid shall be recoverable under the Public Demands Recovery Act, 1913 (PDR Act 1913). The Fees/Charges are given in circular which is given in the website (www.btrc.gov.bd). Application without the submission of complete documents and information will be rejected. For Renewal, please attach a photocopy of the existing license. Payment should be made by a Pay order/ Demand Draft in favor of Bangladesh Telecommunication Regulatory Commission (BTRC).