Customer information (as shown on utility bill) Bill Account Number (11 digits) * First Name * Last Name * Address 1 * Address 2 City * State Zip Code Contact information First Name * Last Name * Email Address * Confirm Email * Phone Number * Is customer's primary language other than English?* YesNo Is your household eligible for California Alternative Rates for Energy (CARE)?* YesNo Site information Dryer Heat Fuel * —Please choose an option—ElectricI do not own/use a dryerNatural GasOther Water Heat Fuel * —Please choose an option—ElectricOtherNatural GasPropane Primary Heat Fuel * —Please choose an option—ElectricOtherN/ANatural GasWood Cooling Type * —Please choose an option—Heat PumpElectric Heat PumpNoneCACElectricEvaporative CoolerOtherN/A Percent Cooled * —Please choose an option—1008095 Home Size * Home Type * —Please choose an option—Single-FamilyMulti-FamilyManufactured Home Year Built * Do you rent/lease the location where the product(s) were installed?* YesNo Are you the property manager? * YesNo Receipt information Purchase Date/Receipt Date * Purchase Price/Install Cost * Upload electric copy of receipt: * Additional Attachments: Product information Quantity * Manufacturer * Model Number * Serial Number * Where product was purchased: * Online purchasePurchased at physical retailer storeVendor/contractor supplied Retailer Name * Payee - Customer Same as contact info: * YesNo First Name * Model Number * Address * City * State Zip Code Payee - Contractor Company Name * Address * City * State * Zip Code * Δ Customer information (as shown on utility bill) Bill Account Number (11 digits) * First Name * Last Name * Address 1 * Address 2 City * State Zip Code Contact information First Name * Last Name * Email Address * Confirm Email * Phone Number * Is customer's primary language other than English?* YesNo Is your household eligible for California Alternative Rates for Energy (CARE)?* YesNo Site information Dryer Heat Fuel * Water Heat Fuel * Primary Heat Fuel * Cooling Type * Percent Cooled * Home Size * Home Type * Year Built * Do you rent/lease the location where the product(s) were installed?* YesNo Are you the property manager? * YesNo —Please choose an option—ElectricI do not own/use a dryerNatural GasOther —Please choose an option—ElectricOtherNatural GasPropane —Please choose an option—ElectricOtherN/ANatural GasWood —Please choose an option—Heat PumpElectric Heat PumpNoneCACElectricEvaporative CoolerOtherN/A —Please choose an option—1008095 —Please choose an option—Single-FamilyMulti-FamilyManufactured Home Receipt information Purchase Date/Receipt Date * Purchase Price/Install Cost * Upload electric copy of receipt: * Additional Attachments: Product information Quantity * Manufacturer * Model Number * Serial Number * Where product was purchased: * Retailer Name * Online purchasePurchased at physical retailer storeVendor/contractor supplied Payee - Customer Same as contact info: * First Name * Model Number * Address * City * State Zip Code YesNo Payee - Contractor Company Name * Address * City * State * Zip Code * Δ
