2024 Rebate Form - Appliances, Recycling, Lighting, HVAC, Water Heater

Member Name (first and last)

Email Address

Service Address (fire # and street name)

City, State, Zip Code

Mailing Address (if different from service address)

City, State, Zip Code

Primary Phone

Secondary #

Cell Phone #

Office/Work #

Ext #

Type of Service

Account #

Location #

Today's Date

Types of Rebates to Choose From

Appliances

Recycling

Lighting

HVAC

Water Heater

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POLK-BURNETT ELECTRIC COOPERATIVE