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2011 New Jersey Natural Gas Company SAVEGREEN Project� Rebate Application Instructions, Terms and Conditions A.CUSTOMERS- TO QUALIFY FOR YOUR REBATE, YOU MUST: 1. Purchase and install, on or after April 11, 2010, but by no later than December 31, 2011, a high-efficiency furnace or boile er- formed by a participating BPI certified auditor. ll required information to process your rebate Form# 620-001 New Jersey Natural Gas Account Number: Account Holder First Name: _______________________ Account Holder Last Name:__________________________ Installation Address: ____________________________________________________________________________ Zip:________________________ Daytime Phone: _____________________________ Account Holder E-mail Address: __________________________ REQUIRED FOR REBATE: REQUIRED FOR REBATE: I want to learn more about E-Tips, NJNG�s monthly e-mail service featuring programs, rebates and tips to save energy. I have read, understood and comply with all of the rules and regulations concerning this rebate program. I certify that all inf correct to the best of my knowledge, and I grant New Jersey Natural Gas Company permission to share my records with the State o f New Jersey, Board of Public Utilities or its contractors, who plan to evaluate my energy usage. I hereby grant to New Jersey Natural Gas Co is the subject of this rebate application. Further, I understand and agree to comply with all of the terms and conditions of th Application must be postmarked within 120 days of purchase date. Customer Signature: ____________________________________________________ Date: ____________________ First Name: _____________________________________ Last Name:____________________________________ Daytime Phone:________________________ Mailing Address:________________________________________________________________________________ Zip:________________________ Customer Signature: ____________________________________________________ Date: ____________________ Company Name:________________________________________________________________________________ First Name: _____________________________________ Last Name:____________________________________ Zip:________________________ E-mail Address: ________________________________________________________________________________ Phone Number:: _____________________ Fax Number: _____________________ :________________________ :________________________ Gas Furnace with ECM connected to Central Air Conditioning Purchase Date: _______________________ Manufacturer: ______________________________________________ Model Number: __________________________ Serial Number: __________________________________________ (Check one, if applicable) For Office Use Only Date Received: ______________ AFUE: __________________ Approved: _________________ Form# 620-001