energy efficient appliance rebate program - City of Centralia

CENTRALIA LIGHT
ENERGY EFFICIENT APPLIANCE APPLICATION FORM
Name Phone
Mailing Address
PO Box
City, State, Zip
Service Address Where Installed
Appliance Type: Clothes Washer Freezer Refrigerator
Supplier
Brand/Make
Efficiency Rating (if applicable) MEF- Model # -
Does this home have an electric water heater? Yes No If no, water heater type
!!! A copy of the purchase receipt must be attached to this form !!!
Date Purchased Date Installed
THE APPLIANCE MUST BE AN ENERGY STAR® CERTIFIED MODEL TO QUALIFY FOR THE
APPROPIATE REBATE.
Check the efficiency rating of the appliance to make certain it meets the program’s requirements
before it’s purchased and installed.
Once this form has been completed and a copy of the purchase receipt has been
attached, return it to:
Centralia City Light
ATTN: Light Conservation
1100 N Tower Avenue
Centralia, Washington 98531
All rebate requests must be submitted on or before September 15, 2012 to be eligible for
payment.
If you have any questions please contact the Conservation Department at (360) 330-7512 ext. 293.
FOR OFFICE USE ONLY
Date Verified
Verified By
Approved for Payment Yes No Amount
Invoice No.
forms/light/crd/appliancrebate/pd/Oct-11