Applicant Signature
Program Terms and Conditions: Please read the program terms and conditions [here](link to terms and conditions). By signing this form, you agree to adhere to these terms and conditions.
Program Participation Agreement: Please read and fill out the program participation agreement template [here](link to participation agreement template).
User Payment Agreement
I certify that I am authorized to act on behalf of the vendor and complete enrollment in the Energy Savings Rebate Program, and to the best of my knowledge and belief the information supplied is true, complete, and accurate for the purposes of this Request for Payment. I am
aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims, or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729 - 3730 and 3801 - 3812). I acknowledge that payments are issued in reliance of this certification, and false statements, misrepresentations, or material omissions may be the basis for immediate termination of the enrollment, termination of the Direct Pay Agreement, and repayment of all funds received.
Please sign below
Note: Please review and ensure all required documents are attached before submitting the form.