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i <br /> � , <br /> t <br /> Backwater Prev�ntion Device <br /> � <br /> Rebate Pr�Ogram <br /> � � <br /> For internal Use: P���ct Numher _____ <br /> Ve'nr�or Payment Option Form : <br /> � � <br /> � Pleasc complete both sides of the form � <br /> Property O�amer Section (please print): i <br /> , <br /> 1- ---. _ - -- —--- � , <br /> - ----- -- ' <br /> � - �s.,��_Lt�-�C.___ --- � ; <br /> -- -�---- -- — <br /> Pr perty Owner Name t i <br /> _ 2_�.l�__C.CdQt�s� �vt-rc--�9- -!__1a.�'�__ Fs'Zo � , <br /> Pr perty Address City Slate Zip ; <br /> i •--- ---- --1----- - ----- I <br /> Allemale Mailing Address City Slate Zip <br /> r , <br /> I y�=�a�__b3��---- ' -��►iQS�'-�'�mc��- .n.�f- <br /> I --Ph'one Finail , ; <br /> � r —-- <br /> I, the Property Owner, reyuest to h2ve the City of Evu�ett Dackwater Prevr.ntion Device � <br /> r�bal check (or the installation referenced at lhe nroperty Address be made payable ; <br /> to, and sent to, fhe Vendor. By requesling the incenti�e/rebate check be made payable <br /> to th 1 Vendor, I agree to the following: , � <br /> I <br /> 1 � I will not r�ceive .� f.�a�kwater Prevention Devicle iebate check d�rectly frorti tlie <br /> City of E:verett. ; <br /> 2.' �ssi�ning �ayment uf the L;ackwater I'reventio Devir,e rebat� to the Vendor � <br /> does not exernpl me frorn Ciackwater PrevenUo'n Dr,vice fiebate Proyram � <br /> requirements. ' <br /> I i <br /> _ <br /> I au� inrize lhu release o( my rebate: to Ih�� Vendor lisled on page two nf this form ! <br /> penc�ing �pproval u(the r.ompleteA D�ckwalei 1'icvehlion Device rebate par,kage by <br /> Nie City of t,verett <br /> -� : _ ---_ _ _ _ --I. a"a� �o� � <br /> , <br /> .��- _ ,���.- 1_1___�_ <br /> 3i n,3ture o pert�� Owner I Uate ; <br /> __ I <br /> � � <br /> � <br /> Hevised sr:�ao�a P�sR t ��r z `. <br /> � <br /> � <br />