Cable Consent Form

Cable Consent Form
I, Name* agree to pay my monthly share of the Cable bill at the Triangle residence in which / reside. My share of the monthly bill will be approximately $ Amount* . This includes basic cable service and remote control for the living room television. If I chose to have cable television installed in my bedroom, I agree to pay the one time installation fee in addition to a monthly fee for this additional service.
Any additional charges for special events or services (i.e. Pay Per View or movie channels) will be divided equally among those individuals who request the service. Individuals will be responsible for payment only after signing a consent form that specifies the date and service requested.

I understand that I am free to withdraw consent at any time. This consent expires after
Individual's Signature*

Clear
Date*

MonthDayYear
Date
Procedure used to obtain consent:
Signature of Person Obtaining Consent

Clear
Date

MonthDayYear
Date
Legal Guardian's Signature*

Clear
Date*

MonthDayYear
Date

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