High-Efficiency Appliance Recycling Rebate Claim
Applicant Information
Full Name
Mailing Address
City
State
ZIP Code
Phone Number
Email Address
Appliance Details
Appliance Type
Refrigerator
Washing Machine
Dryer
Dishwasher
Other
Brand
Model Number
Serial Number
Purchase Date
Recycling/Removal Details
Recycling Pickup/Drop-off Date
Recycler/Hauler Name
Receipt Number
Additional Notes