2. Name
3. Customer Number
5. Location ID
6. Phone
8. Installation Address
10. Rebate Information

    1. 1.28 gallon single flush
    2. 1.28 gallon dual flush
    3. Senior / 100% Disabled Veteran Installed

    Select rebate type and number (maximum of 2 rebates)
12. Toilet Information
14. New Toilet Manufacturer and Model
16. Purchased From
17. Installation Date
    Installation Date
19. Installed By
21. Supporting Documentation
23. I hereby certify that I have read the terms and conditions and understand the contents thereof and agree to the terms and conditions of this rebate program, that I have replaced a pre-1993 toilet, and that the facts stated herein are true and correct.

    1. Yes
25. Name
26. Date
    Date
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field