ENERGY STAR Appliance Rebate Form
Applicant Information
Full Name
Phone Number
Address
City
State
ZIP Code
Email Address
Appliance Information
Appliance Type
Brand
Model Number
Serial Number
Purchase Date
Retailer Name
Proof of Purchase (Attach/Description)
Certification
By submitting this form, I certify that the information provided is complete and accurate, and the product meets ENERGY STAR requirements.
Applicant Signature
Date