ENERGY EFFICIENT APPLIANCE REBATE FORM

OKANOGAN PUD
PO BOX 912
1331 2ND AVE N.
OKANOGAN, WA 98840
DATE:

Where and to whom should the rebate check be sent?

Name:
Mailing Address:
City: State: Zip Code:
Telephone Number: ( )

Where was the appliance installed?

Customer Name:
Customer Account Number: (Located at the top of your utility bill.)

Physical Address (No P.O. Boxes):

City: State: Zip Code:

What appliance was purchased?

Appliance Type (refrigerator, water heater, etc.):
Appliance Brand: Model Number:

NOTES:
ü Please attach the energy guide label from the appliance and an original paid receipt
to this form. Forms without an energy guide and receipt attached will be
returned to the customer.
ü Forms can be hand delivered or mailed to the PUD Conservation Office at the
address listed above.
ü The original receipt and energy guide label will be returned to you if requested.
ü Rebate checks are mailed to the customer and are mailed separately from the
returned receipt and energy guide label.

I certify this appliance was purchased for installation at the above listed
physical address. I will allow a representative of the utility to verify installation
of the appliance if requested.

BUYERS SIGNATURE:

UTILITY REP SIGNATURE:

Version 1/8/04