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<br /> ;Backwater:Prevendon Qevice Rebate Program : �'
<br /> . . ' Vendor Payriienf Optlon Fo�m ' ''
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<br /> � Pro�ect Number ; (Citylo Prowde) _ ; �;I
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<br /> � - Please compiete both s�des of the form ;; , � " ' �
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<br /> •::: Property Owner Section ••: :..
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<br /> . •Pro�Ay Owner Name ��� 1 uC�C�c�,l i l7 (.l.Ol ��: 6 I Ci� ` • : �
<br /> Installetwn Address ' � ll/�� •�� ��K--S � I
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<br /> . � City .�V 1'2.—�T • :.. State �:-�- Zip � �
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<br /> Mailing Address(if d��erenfJ: ` �, '
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<br /> •��._:� :' . Cilty..... .;`. . ;._� �.:. . '.S1GtC r..� '-� � :-.Z'IP. .. ;• , �.i
<br /> EmaH: �l V� Fho'ne:�-2���,--.•�S� �S`Z= .1
<br /> . ` D`M � �►'I . " •`Gl3M ' .
<br /> ' Tatel Cost to Insleil Dovice(fNm oo tracforinvoke) 3 ' � • , �
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<br /> I,the property owrier,requesl to havs the Gty of Everatt Beckwater PreveMlon Oevice�ebate chedc
<br /> for tha inafa�etion at tl�o davica nt tho abode refeienced property address be made payable to,and
<br /> sont to,the vendor spedfied on(he.back of this form, By requeating ihe rebate dieck ba mede � �
<br /> payable,to ihe Jendot 1 agree to the follo+nnng:�•; ' ' I
<br /> •, 1 I will not recerve a rebate check diredly fromlhe Cily of EvereB `. , � , :,I
<br /> ,, i.� ', •2: Assigning payment of the rebate t6 tlie venda does not exeinpt me from Badcwater •
<br /> �Prevention Device Rebate Program requlrements ---`• , .,.�
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<br /> : 'I�aulhotlze the�efease of my rebate.to tfie vendor,fisted on tha back of,this fam pending ,;. ; , ' ' , ' !
<br /> apprbvo�bf the compietad 8ackwater Prevendon Device'rebate pepkef by the City o(Everett ��
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<br /> ���`IX� ' f ' ' ' . .
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<br /> ' S{gnature of Propeity Owner, ' ; Date �� � _ �
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