Energy-Efficient Appliance Rebate Form
Full Name
Email Address
Phone Number
Home Address
City
State/Province
ZIP/Postal Code
Appliance Type
Refrigerator
Washing Machine
Dryer
Dishwasher
HVAC
Other
Brand
Model Number
Purchase Date
Store/Dealer
Purchase Price
Serial Number
ENERGY STAR Certified?
Yes
No
Additional Comments