Rebate Application
Hybrid Electric Water Heater
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.
Do you own or rent?
*
Own
Rent
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Home Type
*
Single Family
Manufactured
Multi-Family
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Install Location
*
Conditioned Space
Unconditioned Space
Install Room
*
Room Size (LengthxWidthxHeight)
*
Total Cubic Feet
Make & Model Water Heater
*
Size (gallons)
*
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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
Date
Submit
Should be Empty: