Ohio Propane Vehicle Rebate Application

Ohio Propane Vehicle Rebate Application
Submit this completed form with the required documentation to the Ohio Propane Gas Association (OPGA) at the address at the bottom of this page.
To apply for this rebate:

1) Applicant and the applicant’s propane marketer must sign the application;
2) Attach the invoice for the vehicle or retrofit system; and
3) Keep a copy of the completed application and all necessary documentation for your records.

All fields are required:

If you have any questoins, please contact to cr@crmarketing.biz
Rebate Pre-Approval #*
VEHICLE OR MOWER INFORMATION
Make Model Year*
Vehicle Identification Number (VIN) or Serial Number**
Vehicle Purchase Date*

MonthDayYear
Date
*If the VIN or serial number are not available, please submit a copy of the sales invoice or sales order from the manufacturer or supplier.
APPLICANT INFORMATION (where the rebate check will be mailed)
Make check payable to:*
Name*

First NameLast Name
Company*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Fax*
Propane Conversion System*
Install Date*

MonthDayYear
Date
Manufacturer of System*
Installer*
VIN or Serial Number of System
I understand that this rebate is available only through authorized propane marketers in the state of Ohio, that it is not a government program, and that the program may end at any time. I understand that the Ohio Propane Gas Association assumes no responsibility whatsoever for the vehicle or mower and, by issuing a rebate, makes no representation, warranty or guarantee regarding the qualifying vehicle or mower system. OPGA disclaims any liability for any personal injury, property damage, business losses, or any other damages of any other nature whatsoever, whether special, indirect, consequential or compensatory, directly or indirectly arising from the use of the vehicle or mower.
Applicant Signature*
Date*

MonthDayYear
Date
PROPANE MARKETER INFORMATION
Name*

First NameLast Name
Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Fax*
Email*
example@example.com
I understand and agree to all rules and conditions for participation in this program. I hereby declare that I am authorized to sign this application and that the information stated herein is true, correct and complete to the best of my knowledge.
Company Representative Signature*
Date*

MonthDayYear
Date
Ohio Propane Gas Association Data Collection Incentive
Contact Information
Name

First NameLast Name
Company
Phone Number

Area CodePhone Number
Email
example@example.com
I acknowledge that this is a Data Collection Incentive, and that an initial survey and final survey must be completed electronically for each vehicle or mower receiving an incentive. Additionally, for one year from the time the rebate is received, I am required to submit a quarterly report of miles driven, gallons of propane used, and anecdotal performance characteristics.
Signature of Applicant
Date

MonthDayYear
Date
Signature of Propane Marketer
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Ohio Propane Vehicle Rebate Application

Ohio Propane Gas Association Data Collection Incentive