Gas Rebate Application

GAS APPLIANCE REBATE APPLICATION

* NOTE *

* Appliance must be installed and Fueled by natural gas only.

*Sales receipts must be submitted with this application & indicate date of purchase, dealer's name, appliance purchased, and brand of the appliance.

Customer Information

Applicant Name*

Account Number*

Applicant Address*

Phone Number*

Appliance Location Address

Email*

example@example.com

Appliance Information

Type of Natural Gas Appliance*

FurnaceWater HeaterDryer

Date Purchased*

Quantity*

Energy Efficiency Rating*

Brand*

Model #*

How would you like your rebate issued?

Chamber DollarsApplied to Account #

Customer Certification and Agreement

The systems(s) at the above address has been selected and installed in accordance with guidelines established for the EMU appliance rebate program. The customer understands that prior to the issuance of any payment; the equipment may be inspected by EMU. The customer shall observe and comply with all ordinances, laws and requirements of all units of government and governmental agencies having jurisdiction over the work to be performed. EMU does not guarantee that the equipment funded under this program will result in energy savings. In no event shall EMU be liable for any incidental or consequential damages.

Customer's Signature*

Date*

Acknowledgement of Required Documents*

I agree to mail a copy of my Receipt/Invoice to: Emmetsburg Municipal Utilities - P.O. Box 417 Emmetsburg IA 50536I will email my Receipt/Invoice to jshirk@emmetsburg.comI will upload my Receipt/Invoice below

File Upload for Receipt/Invoice