Water Heater Rebate Application
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 #: _________________________ | |
| Date Purchased _______________________ | Date Installed _________________________ | |
| Brand Purchased ______________________ | Tank Size _________________gallons | |
| Model #___________________________ | Serial # ___________________________ |
Reason for Installation: (Please check only one)
| New Installation ___ | Electric w/h replacing electric___ |
| LP gas replacment ___ | Natural gas replacement___ |
Primary Heating System: (Please check only
one)
| Ground Source Heat Pump ___ | Electric air source heat pump___ |
| Electric furnace ___ | Electric baseboard___ |
| Natural gas furnace ___ | Propane gas furnace___ |
| Wood ___ | Other _______________ |
| Amount of Rebate _______________ |
| Approved by ___________________________ |