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N Backwater Prevention Device <br /> --�• � Rebate Program <br /> For internal Use: Project Number. <br /> Venclor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> �a � /�-�-� �a�— <br /> 1�Pro erty O�vner N me <br /> s_� ,�. ,�C��b4- �.Jq 9 k,-o/ <br /> Properly Address Cily State Zip <br /> Allernate titailing Address Ciry State ZiP <br /> Phone Email � <br /> I, the Prcperty Owner, reyuest to have the City of Everelt Backwater Prevention Devi�e <br /> rebate check (or Ihe installation referenced at the Property Address be made payable <br /> to, and sent lo, the Vendor. By requestiny the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: <br /> 1. 1 �vill not receive a Backv,�ater Prevention Device rebat^ check directly from the <br /> City o(Everett. <br /> 2. Assignina paymenl of the f3ack�vater Prevenlion Device r�:bate to ihe Vendor <br /> does not exempl me irom Back�vater I'revention Device Rebate Program <br /> re�auirements. <br /> I auliiorize the release of my reberie to the Vendor listed on page two of this form^ <br /> pending approval nf the completed f3ackwaler Prevention Device rebate package by <br /> lhe City o( Evere(t <br /> ��� G� ����—__ ��/�3 /ze j— <br /> Siyna ure o( - aperty Ownei r Dale <br /> �� _'_. . __� <br /> Page 1 of 2 <br /> Revised 9/?/7.01ti <br />