8296 SW 103rd Street Road  
Suite 3  
Ocala, FL 34481  

Authorization Agreement Automatic Debit Form

Print this form and fill it out completely and return to Cablevision at the above address.
 
I (we) authorize CABLEVISION OF MARION COUNTY LLC and the credit card company listed below to electronically debit my (our) credit card specified below:
 
____________________________________
CREDIT CARD TYPE
(Visa, MC, Discover, other)

____________________________________
NAME (as it appears on credit card) 

____________________________________
ACCOUNT NUMBER


_____________________________________
EXPIRATION DATE


____________________________________________________________________________
CABLEVISION ACCOUNT NUMBER(S)


This authorization is to remain in effect until COMPANY and CREDIT CARD INSTITUTION have received written notification from cardholder to terminate this Agreement.  Upon receipt COMPANY and CREDIT CARD INSTITUTION will make the requested changes in a reasonable and timely manner.  I (we) understand that cardholder must inform COMPANY immediately of any changes to my (our) credit card, including but not limited to, expiration date, name and/or number.  Fees may apply should cardholder fail to notify COMPANY of such changes.

 ______________________           ______________________
NAME (Please Print)                                                 SIGNATURE