Energy Star Rebate Application

Energy Star Appliance Rebate Form

Please fill out this form after purchasing a new energy star appliance(s) for your primary residence to apply for a rebate with Four County EMC. Eligible appliances include dishwashers, washing machines, dryers, refrigerators, and freezers. We will give you a $50 bill credit for each approved appliance. For example, if you submit a washing machine, dryer, and dishwasher that are all new energy star appliances, you will receive a bill credit for $150.

Date(Required)

Name(Required)

First Last

Address(Required)

Please enter your physical address and not a PO Box.

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

We will communicate about the rebate(s) with you through email.

Please select the new appliance(s) that you purchased and are requesting a rebate for(Required)

Please select all that apply.

Dishwasher

Washing Machine

Dryer

Refrigerator

Freezer

Please enter the brand and model number of your dishwasher(Required)

Please enter the brand and model number of your washing machine(Required)

Please enter the brand and model number of your dryer(Required)

Please enter the brand and model number of your refrigerator(Required)

Please enter the brand and model number of your freezer(Required)

Please submit a copy of your receipt. If you purchased a new home that came with new appliances, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead of the receipt.(Required)

Max. file size: 300 MB.

Do you have a second receipt?

Yes

Please submit a copy of your second receipt.(Required)

Max. file size: 300 MB.

Do you have a third receipt?

Yes

Please submit a copy of your third receipt.(Required)

Max. file size: 300 MB.

Please submit a copy or picture of your energy guide for your dishwasher. If you don't have the energy guide, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead.(Required)

Max. file size: 300 MB.

Please submit a copy or picture of your energy guide for your washing machine. If you don't have the energy guide, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead.(Required)

Max. file size: 300 MB.

Please submit a copy or picture of your energy guide for your dryer. If you don't have the energy guide, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead.(Required)

Max. file size: 300 MB.

Please submit a copy or picture of your energy guide for your refrigerator. If you don't have the energy guide, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead.(Required)

Max. file size: 300 MB.

Please submit a copy or picture of your energy guide for your freezer. If you don't have the energy guide, please submit a clear photo of the model/serial number or the appliance showing the energy star symbol instead.(Required)

Max. file size: 300 MB.