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i <br /> Backw��ter Prevention Device ; <br /> ,' Fv�rr Rebate Pro ram <br /> � <br /> I ni inlqinnl U�;�f. I'i� ���_J PJi�r.: � i <br /> Vendor Payment Option Form <br /> Plcatic r.unqilrtc liotli sidr� of thc fonn <br /> Property Cwner Sectioii (pler�sc print): <br /> --- - _._ _ . _ ._.. <br /> � _ _... ._ <br /> � �c-i4 `( 12�1 �+_��,�� IL I <br /> - --. <br /> � Pro�;erty p;;rc� �Ja�ne <br /> � ,-. �`� 1 �C <br /> � _a S.? _t� z <br /> � Piot �.rty f"�ddrr.,s �, �y __. -- ' Sl;il�• 7m I <br /> i <br /> - ------- --- - - _ _. ___.. . _ ... _ _ _ � <br /> Allein�alo Mailiny Addres, Gty `�I,du 7��, � <br /> I — - --- --- _ .- - --- ._. . _-- _. _ _ _ ' <br /> Phone I mail <br /> I . -- .__ _—. ----------_ -_----___ _ _ -- I <br /> I. ihe Property Owrer, reque;l to h�rv�� Ilu� Ci;y o( �v��r��tl fiar,hwa�rn' f'rrrvr;nl�on Ucvu:�� <br /> iebate chFck for �hr_ ms�ullalion rc(crcnccd a( the Pm��cily /lil�hi:ss lir, nctdr� ��;iynh'� <br /> tu. a�d �a�nt lo. Ihu V�mdor Hy icyucsting ihe uicenlivr./iuhrdu cli�:r.k l�c nridc ��,iyul,I�• <br /> tu th�� Vendor, I ayrce to !he fullowing <br /> 1 I will not rer.eivi� n fi:icrw,ile� f'ievenl�un I)evice rul�nle i.herk dueclly (iuni Iln� <br /> Cily o( [vcroU <br /> : llssigning payment i�f Ih�,� 13ackvr�fer I'reventum D�rwr,r� i��lc�(�� �u Ihe Vr.ndn� <br /> �locs r.ot exu�npl inc huri R:ick�v.ih�r I'rrrvcnt�on Ucv�a; I�cI�;�G• I'iuq�,ini <br /> icquiremenl; <br /> I a;:lhunzu �hc r��lc�isc uf niy ii�h��'c lu ihc Vcndni Ir l��il nn ��,i�p� Iwr� ul luc: I�un� <br /> �i�•ndinq ��pproVrll ��f �I��r r��i�i��'��Iri! It,ii.k�a�i(r�� ('ii^1��n!iun I ).•vn t• ���li.it�• �;.i� k,n��� !i�� <br /> Ihn i:�ty of Cvcrett <br /> /� .� <br /> ���'l,� O � - ZS - �o/s <br /> '�,�7n�t ,il� [ I'icmr�l�� r h:-,r��i I r.�r,� <br /> i',i�li� 1 �;� ; <br /> I'i - i � �� , �:��1��1 . <br />