Cable/Phone Sign Up

Fiscal Services Related Items Cable/Phone Signup

Extended Stay -- Addendum III
Resident Name*

First NameLast Name
Room Number*
Telephone:

Incoming calls are included. Outgoing phone service is $15.00 per month. A Personal Allowance Account (PNA) is required to bill.
Television:

I understand if I have cable service through Andrus On Hudson that the cost is currently $31.00 per month. A Personal Allowance Account (PNA) is required to bill. If I would like to obtain additional or separate cable services, I must contact Optimum and pay for them at my own expense.
Personal Allowance Account
A personal allowance account is offered to all residents of this facility. I understand that I am under no obligation to authorize this facility to maintain funds in a personal allowance account. However, should I elect to have an account, any money will be maintained in accordance with applicable State and Federal Law by the facility for my personal use.
Please bill from my personal allowance account for

Telephone Services - Current Charge of $15.00 a monthCable TV Service Current Charge of $31.00 a month
Name of Signee*

First NameLast Name
Signature of Resident

Clear
Signature of Responsible Party

Clear
Date

MonthDayYear
Date
Should be Empty:

Fiscal Services Related Items Cable/Phone Signup