Appliance Recycling Form
Contact Information
Jacob Parker Email
example@example.com
Patrick Flannagan Email
example@example.com
Member Account Name:
*
First Name
Last Name
Electric Account Number:
*
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Pickup Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / ZIP Code
Appliance Information
Appliance Type:
*
Refrigerator
Freezer
Window Air Conditioner
Does the Appliance Work?
*
Yes
No
Refrigerator Type:
*
Please Select
Top Freezer Refrigerator
Bottom Freezer Refrigerator
Side-by-Side Refrigerator
Single Door Refrigerator
French Door Refrigerator
Number of Refrigerator Units:
*
Please Select
1 Unit
2 Units
3 Units
Freezer Type:
*
Please Select
Upright Freezer
Chest Freezer
Number of Freezer Units:
*
Please Select
1 Unit
2 Units
3 Units
Number of Window Air Conditioner Units:
*
Please Select
1 Unit
2 Units
3 Units
Pickup Information
Appliance Location
*
Garage
Outside
Other
Rebate Information
Name of Rebate Recipient:
*
First Name
Last Name
Mailing Address
Check if the same as the pickup address.
Rebate Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / ZIP Code
Submit
Should be Empty: