Residential Rebate Application
Washer/Dryer
Name
*
First Name
Last Name
Email
*
example@example.com
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Year Built
Square Feet
Do you own or rent?
*
Own
Rent
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Home Type
*
Single Family
Manufactured
Multi-Family
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Rebate
*
Washer
Dryer
Both
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Washer
Energy Star Top Loader
Energy Star Front Loader
Make & Model of Washer
Washer rebates require that your water heater is electric. Please confirm that your water heater is an electric unit.
*
Yes, my water heater is electric
No, my water heater is not electric
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Make & Model of Dryer
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Please make check payable to
*
Member
Contractor
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Contractor Name
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Supporting Documents
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Signature
*
Member Signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: