Optimum

Cablevision of:

Name of Applicant:

Address:

City, State, Zip:

Telephone # (Home):

Telephone # (Work):

Equipment request:	Date: Time:

Applicant has inspected the equipment listed below and agrees to return equipment in workable condition to the access department.

Item 1: Description: Condition:

Item 2: Description: Condition:

Item 3: Description: Condition:

Item 4: Description: Condition:

Item 5: Description: Condition:

Item 6: Description: Condition:

Equipment Due Date:	Date: Time:

Applicant assumes full responsibility for the proper care of Cablevision access equipment which may only be used for the production of access programming. Damage to equipment may result in loss of access use privileges. Applicant bears financial responsibility for the repair or replacement of equipment damaged while in the care and custody of Applicant in accordance with Cablevision's Access Rules and Contract which are incorporated herein.
Applicant's Signature: ________________________________________ Date: ____________
Equipment returned on:
Access Department Return Verification: _________________________ Date: ____________

Please fill out the above form, then click below to print it. Sign and date the form and mail or fax it to your regional access programming office.