Laserfiche WebLink
�M� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Proiecl Nurnbei --. - -- -- - (Qf��!'i Pr��wde) <br /> Please complete 4�oth sides of the form <br /> Property Owner Section: <br /> , - -- — - <br /> � f'roperty Owner Narne �(f{ r� �J �)_l_�[1_C,�__. <br /> � r- - - <br /> Install�tionAddress �_ C,P1"�(jr r��[e.�� _ <br /> Cily. _�v�-.�e-1�_— St,te� �Uf� . Ziu. 7 $o?O� _J <br /> �� Mailing Address (if ddlerFnf � <br /> ' � --- - --- -- <br /> City St�te Zip <br /> Email. - ----.-- - - -Phone• ( ) _ ._ <br /> Total Cost to Inslau Devlce (Irom cnnhacfor mvrnce) $ 1,'�_GG _ <br /> I, the prpperty ownr.r. reyuesl lu!�ave the Cdy oi Everell Backwaler Prevenhon Dewce rebate check <br /> (or ihe installatiun of the device al the above referenced pioperty address be made payahle to. and <br /> senl tu. the vendor specihed on R�e back of Uus larm. By requesting Ihe reLate check be made <br /> payablc to Ihe vr_ndor, I aqree to Ihe followmy <br /> 1 I will nol rucewe a rebate check drcectly Irom Ihe City of [veiett <br /> �' Pss�yning p��ymen� of�he rnbale to Ihe vendor dnFs not exempt m�� f�om Aar.kwalr.r <br /> i'���vrntion Dewce Rebato f'roq�am reqwremenls <br /> _ -_ . --- -- --, <br /> i <br /> I auBionic ihe release ol rny rebate to the vendor lisled on Ihe bir,k ol Ihis fnnn pendmy <br /> approval of ihe complt+led l3ackw�ter PrrvPntinn �evirr mMte packel by thr City ol Evnrett <br /> � <br /> � -� �} ��--- -- -- �5�� 7-.-�'OIS I. <br /> Signatur�perty Ownei Date <br /> -- - ---- ----�-- — -- ---� <br />