Satellite Application & Disclaimer FormPlease enable JavaScript in your browser to complete this form.Tenants Name *FirstLastTenant's Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeContact Phone NumberEmail *Please tick which of the following you wish to install: TV AerialSatellite DishAntennaeConfirm where the TV aerial will be sited (include a diagram of proposed location) Confirm what type of antennae will be installed and where is will be sited (include a diagram of proposed location) Details of the Company carrying out the installation:Company NameCompany AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeCompany Contact Person's NameCompany Contact Person's Phone NumberInsurance CoverDo you have the appropriate risk insurance cover in respect to public liability and home insurance covering the installationYesNoNot SureI confirm that all risk insurance cover in respect to public liability and home insurance covering the installation and use has been arranged with the following company.Insurance Company NameInsurance Company AddressAddress Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryInsurance Policy NumberI / we confirm that I / we do / do not have home insurance to cover for liability for the installation of the aerial/satellite dish/antennae and take full responsibility for any incidents. I/We Confirm ThisI / we agree that Cunninghame Housing Association cannot be held liable for any incidents which relate to the installation of the aerial/satellite dish/antennae. I/We Confirm ThisI/we understand that I/we cannot proceed with installing the TV aerial, Satellite dish or antennae until written permission is received from Cunninghame Housing Association Ltd. I/we understand that if I/we install prior to receiving written permission Cunninghame Housing Association will request that I/we remove the installation.I/we understand that a member of staff from Cunninghame Housing Association will contact me within 7 days to discuss my application and I/we will be asked to confirm two security questions. If I/we fail to make contact my application will be refused and I/we would need to make a further application. I/we understand that the Association will formally respond to the application in writing within one month of the application being made confirming if the request has been granted or refused.Do you agree with the above Terms and Conditions? *YesCompletion of this application form does not mean consent has been granted. You should not make any changes to your tenancy until you receive a letter from the Association advising of the outcome including any conditions relevant to your application. I hereby confirm that the information provided on this form is correct and that any false or misleading information or the withholding of any relevant information may result in the application being cancelled or if it has been approved that this will be revoked. I agree that Cunninghame Housing Association Limited can make necessary enquiries to confirm the details provided are correct. I agree to the above statement *YesTenant Signature *By typing your name here you are digitally signing this formTodays DateSubmit