Application for Service

McNabb Cable & Satellite, Inc.

308 W. Main St.

P.O. Box 218

McNabb, IL  61335

815-882-2202

Date:_______________________________________

            Applicant’s Name:_______________________________________________

            Address:_______________________________  P.O. Box__________

            Social Security No.________________________________________________

            Drivers License No._______________________________________________

            Telephone No.___________________________________________________

            Place of Employment:_____________________________________________

            Employers Phone No._____________________________________________

            Installation Fee:$35.00_________ Includes 1 Month of all Cable Services

            Extra Outlet: $35.00 Each

            Deposit: $50.00________ To be credited to your account after 1 year, if

                                                       payments are made on time each month.

            This is to certify that all above statements are true and correct.  In the event that

            any past-due balances are placed for collection, all charges will be the

            responsibility of the subscriber.

            Signature:_______________________________________________________