LED Lighting Retrofit Rebate Application
Applicant Information
Applicant Name
Organization/Company
Address
City
State/Province
ZIP/Postal Code
Phone Number
Email Address
Facility Information
Facility Name
Facility Address
City
State/Province
ZIP/Postal Code
Facility Type
Office
Retail
Warehouse
School
Other
Approximate Square Footage
Contractor Information
Contractor Name
Contractor Phone
Contractor Email
Project Details
Existing Lighting Type(s) Removed
Existing Total Wattage
Proposed LED Product(s) Installed
New Total Wattage
Total Number of Fixtures/Bulbs
Date of Installation
Additional Project Notes
Rebate Payment
Payee Name (for rebate check)
Payee Address
City
State/Province
ZIP/Postal Code
Attachments
Attach Invoices/Receipts, Product Specs, etc.
Applicant Certification
I certify that the information provided is accurate and the products listed have been installed at the facility indicated.
Applicant Signature
Date