Effective 01/01/05
Please Print this form, complete it, and bring it in to us.
Refund To:
| Name: ______________________________ |  |
Date: _________________________ |
| Address: _________________________ | Line Location: _________________ | |
| _________________________________ | Account #: ____________________ | |
| _________________________________ | Telephone: ___________________ |
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| ___ New Installation ___ Replacement | What type was replaced? __________ |
| Date heating system purchased _____________ | Date sytem wasinstalled ___________ |
| Installed by _________________________________ | |
| Total Rebate Amount ________________ |
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