Cable/Phone Sign Up

Fiscal Services Related Items Cable/Phone Signup

Extended Stay -- Addendum III
Resident Name *

First Name Last 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

I authorize Andrus On Hudson to open an account in my name or the resident's family name. No, I do not wish to open an account.
Please bill from my personal allowance account for

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

First Name Last Name
Signature of Resident

Clear
Signature of Responsible Party

Clear
Date

Month Day Year
Date
Should be Empty:

Fiscal Services Related Items Cable/Phone Signup