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2. 
3. Appliance Rebate Form

   Homeowner must supply and attach a copy of the invoice that provides the make and model number

4. Date
   Date
6. Account Number *
7. Phone Number *
9. Name *
10. Installation Address, City, State, Zip*
12. Mailing Address (if different):
14. City
15. State
16. Zip Code
18. What type of Water Heater do you have?

    1. Electric
    2. Gas
19. What type of Dryer do you have?

    1. Electric
    2. Gas
21. Clothes Washer Make
22. Clothes Washer Model Number
24. Clothes Dryer Make
25. Clothes Dryer Model Number
27. Upload Invoice or Receipt*
29. Upon signing this agreement, cutomer acknowledges the following:

    Rebate offer(s) may be changed or discontinued at any time by Forest Grove Light & Power (FGL&P).  FGL&P disclaims any warranty, whether expressed or implied, regarding the product(s) listed above for any materials or labor associated with installation, maintenance, repair, or any energy savings associated with use.  Rebate offer(s) applies to new product(s) only.  FGL&P reserves the right to inspect installed product(s).  Product(s) must meet all program criteria to qualify for rebate(s).  I understand the above and certify I am a customer of FGL&P, that the product(s) is/are installed and operating at the location indicated above.  

31. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Electronic Signature
35. UTILITY USE ONLY
37. Reference Number for CW
38. Rebate
39. Savings @ Busbar
40. Payment $/Unit
42. Reference Number for CD
43. Rebate
44. Savings @ Busbar
45. Payment $/Unit
47. Vendor Number
48. Budget Number
50. Invoice Number
51. Signature
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field