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Client Information Sheet

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Cox Client Information Sheet

NAME
LAST:*	FIRST:*	MIDDLE:
ADDRESS
LINE 1:*
LINE 2:
CITY:*	STATE:*	ZIP:*
TELEPHONE
HOME:	CELL:	WORK:	OTHER:
E-MAIL ADDRESS
PERSONAL:	WORK:	SCHOOL:	OTHER:
COX RELATED INFORMATION
Q1. When did you first subscribe to cable television services from Cox?
Q2. When did you first subscribe to PREMIUM cable television services from Cox?
Q3. For how long (years and months if possible) have you been a subscriber to PREMIUM cable television services from Cox?
Q4. Did Cox require that you rent a cable box (also called a "digital converter") in order to receive PREMIUM cable services? YesNo
Q5. Did Cox require you to pay a rental fee for using the cable box (also called "digital converter") in addition to the amount you paid for the actual premium cable services? YesNo



Q9. On your Cox bill, for which of the following items does Cox charge you a rental fee?
Digital Converter	Digital Converter Rental Fee:	Model #:	Serial #:
Digital Converter HD	Digital Converter HD Rental Fee:	Model #:	Serial #:
Digital Converter DVR	Digital Converter DVR Rental Fee:	Model #:	Serial #:
Digital Converter DVR/HD	Digital Converter DVR/HD Rental Fee:	Model #:	Serial #:
Other Rented Equipment	List Other Equipment w/ Rental Fee:	Model #:	Serial #:
Q10. Do you still have copies (electronic, paper, or otherwise) of your Cox bills? YesNo

Q12. To your knowledge, has Cox ever offered PURCHASE of cable box equipment as an alternative to RENTAL? YesNo
Please mail copies of any and all Cox bills to 701 Magazine St. - New Orleans, LA - 70130

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