Water Efficient Technology Application for Notice to Proceed

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)

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.

I have read and understand the policy requirements as stated in the program policy.

Signature

Sign above

Date

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Water Efficient Technology Application for Notice to Proceed