Program Interest Form
Please note: The form must be completed and submitted in one session. If you close the window before submitting, your information will not be saved.
Company Information
Organization Name
*
(Legal Company Name)
Federal Tax ID
*
Company Type
*
Please Select
non-profit
for profit
government agency
Applicant Name
*
First Name
Last Name
Applicant Title
*
Applicant Email
*
example@example.com
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Project Information
Project Title
*
Project Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Estimated Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Project Estimated End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated Equipment Cost
*
Estimated Labor Cost
*
Estimated Other Cost
Total Estimated Cost
Not an editable field. The Total Estimated Cost is automatically calculated.
Project Details
Existing Refrigerant Type(s)
*
R-11
R-134a
R-22
R-404A
R-407A
R-407C
R-407F
R-408A
R-410A
R-417C
R-448A
R-449A
R-453A
R-507
Other
Lbs for R-11
*
Lbs for R-134A
*
Lbs for R-22
*
Lbs for R-404A
*
Lbs for R-407A
*
Lbs for R-407C
*
Lbs for R-407F
*
Lbs for R-408A
*
Lbs for R-410A
*
Lbs for R-417C
*
Lbs for R-448A
*
Lbs for R-449A
*
Lbs for R-453A
*
Lbs for R-507
*
Lbs for Other
*
Description of Existing System: (i.e. Rack system with 150ft of cases and 3000 sqft of walk-in boxes.)
*
Description of Proposed System: (i.e. Transcritical CO2 system, no reduction to refrigerated space.)
*
Proposed Refrigerant Type
*
Please Select
R-744 (Carbon Dioxide)
R-290 (Propane)
R-717 (Ammonia)
SUBMIT
Should be Empty: