Midea Midwest Fall Consumer Rebate Submittal Form

Midea Midwest Fall Consumer Rebate Submittal Form
Name of Person Submitting Claim*
Email address*
example@example.com
Dealership Name*
Dealership Address*
Dealership City*
Dealership State*
Dealership Zip Code*
Dealership Sales Rep Full Name*
Homeowner Invoice Number
Date of Sale*

MonthDayYear
Date
Date of Installation*

MonthDayYear
Date
Total Sale before rebate*
Rebate Amount*
Ductless Indoor*
Model Number*
Serial Number*
Ductless Outdoor*
Model Number*
Serial Number*
Model Number
Serial Number
Model Number
Serial Number
Model Number
Serial Number
Model Number
Serial Number
Full Name (Homeowner)*
Address (Homeowner)*
City (Homeowner)*
State (Homeowner)*
Zip Code (Homeowner)*
Homeowner Invoice (must display rebate deduction):
File Upload*

Cancelof
Auer Steel Invoice:
File Upload*

Cancelof
Signature

Powered by Jotform SignClear
Should be Empty: