Authorization of Cable Services

Authorization to Install Cable Service

Today's Date

Date of Install

First Name

Last Name

Account Number

Phone Number

Street Address

Address Line 2

City

State

ZIP/Postal Code

Name of person authorized at installation.

By Checking this box, I have authorized a person (other than myself) to accept installation of cable, internet, and/or phone service in my absence, and that I will be responsible for this account based on the terms and condition of the subscription and service agreement of Buckeye Broadband.