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2. 
3. HEAT PUMP

   Residential Applicant Project Information Form 

5. Account Number
6. Account Holder Name
8. Phone Number
9. Installation Address

   Include City, State, Zip Code

11. Homeowner Name (if different)
12. Mailing/Homeowner Address (if different)

    Include City, State, Zip Code

14. Email
16. Qualifying Home Type

    Residential stick built and manufactured home. Contact Utility for Multifamily

17. Date of install
    Date of install
18. Upload Invoice or Receipt*
20. Existing Heat Information

    Eligible Existing Heat System Being Displaced (Select One)

21. Existing Heat Type
    -- Select One --Electric Forced Air Furnace Electric ZonalDHPAir or Ground Source Heat PumpGas FurnaceOther Non-Electric
23. AHRI Reference Number
24. Manufacturer
25. Outdoor Unit Model #
26. Indoor Unit Model #
28. HSPF Rating
29. SEER Rating
30. Capacity (Tons)
31. Balance Point
35. 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.
37. Electronic Signature
39. Internal Office Utility Use Only
41. Reference Number
42. Rebate
43. Savings @ Busbar
44. Payment $/Unit
46. Vendor Number
47. Budget Number
49. Invoice Number
50. Approval Signature
52. ADDITIONAL INFORMATION

    Rebate offer(s) may be changed or discontinued at any time.  All warranties are offered through the manufacturer, not the utility, 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) apply to new product(s) only.  Utility reserves the right to inspect installed product(s).  Product(s) must meet all program criteria to qualify for rebate(s).  

Leave This Blank:


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

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field