Chandler Large Water Use Tech Application

Water Efficient Technology Application for Notice to Proceed

Personal Information

Account Number

First Name

Last Name

Primary Contact

Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Check this box if your service address is different from your mailing address above.

Service Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone (Primary)

Phone (Secondary)

Scope of Work

Technology Scope of Work

(Statement of intent, location, where the technology will be installed, installation timeline, list any additions, cost estimate, etc.)

Service Provider Name (if applicable)

Type of Technology

Service Platform

Technology Brand

By submitting this rebate application, you acknowledge that you have read and understand the program policy requirements.

I have read and understand the Water Efficient Technology Rebate policy and requirements.

I have submitted a statement of intent including expected water savings; scope of work; and project cost estimate/bid. Include any research or websites that help provide better operational understanding.

I understand a W-9 is required for all rebates.

By typing my name below, I confirm I have read and understand the program policy requirements, and I consent to this electronic signature as legally equivalent to my handwritten signature.

Electronic signature

Date

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Mayor Kevin Hartke

Water Efficient Technology Application for Notice to Proceed