Bill Account Number (11 digits) *

First Name *

Last Name *

Address 1 *

Address 2

City *

State

Zip Code

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

Dryer Heat Fuel *
---ElectricI do not own/use a dryerNatural GasOther

Water Heat Fuel *
---ElectricOtherNatural GasPropane

Primary Heat Fuel *
---ElectricOtherN/ANatural GasWood

Cooling Type *
---Heat PumpElectric Heat PumpNoneCACElectricEvaporative CoolerOtherN/A

Percent Cooled *
---1008095

Home Size *

Home Type *
---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

Purchase Date/Receipt Date *

Purchase Price/Install Cost *

Upload electric copy of receipt: *

Additional Attachments:

Quantity *

Manufacturer *

Model Number *

Serial Number *

Where product was purchased: *
Online purchasePurchased at physical retailer storeVendor/contractor supplied

Retailer Name *

Same as contact info: *
YesNo
First Name *

Model Number *

Address *

City *

State

Zip Code

Company Name *

Address *

City *

State *

Zip Code *

Bill Account Number (11 digits) *
First Name *
Last Name *
Address 1 *
Address 2
City *
State
Zip Code

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

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

---ElectricI do not own/use a dryerNatural GasOther
---ElectricOtherNatural GasPropane
---ElectricOtherN/ANatural GasWood
---Heat PumpElectric Heat PumpNoneCACElectricEvaporative CoolerOtherN/A
---1008095

---Single-FamilyMulti-FamilyManufactured Home

Purchase Date/Receipt Date *
Purchase Price/Install Cost *
Upload electric copy of receipt: *
Additional Attachments:

Quantity *
Manufacturer *
Model Number *
Serial Number *
Where product was purchased: *


Retailer Name *

Online purchasePurchased at physical retailer storeVendor/contractor supplied

Same as contact info: *
First Name *
Model Number *
Address *
City *
State
Zip Code

YesNo

Company Name *
Address *
City *
State *
Zip Code *