|
Single-Family Residential Application |
|
|
|
Customer Information |
| Date _____________
|
Account #___________________________
|
| Name (print)
_______________________________________________________________________________
|
Installation Address (where toilet is
located)
__________________________________________City:_____________
|
Zip _________
|
| Mailing Address (if different)
__________________________________________City:_____________
|
Zip _________
|
| Home Phone #
_________________ |
Work Phone # ____________________
|
| |
|
Household Information |
|
|
| Year Home Was Built _______ |
# of People Residing in Home_________ |
| # of Bathrooms in Home
_______ |
|
| Replacement Toilet Manufacturer (Brand) ______________________ |
|
|
Model Name or Number
_____________ |
Age of toilet being replaced _____________ |
|
Have you received a previous toilet rebate from the City?
( ) Yes ( ) No |
| Is toilet included on approved listing of ultra low-flush toilets?:
( ) Yes ( ) No |
| Price Paid for Toilet ______________ Date of Purchase ______________ Date of
Installation ____________ |
| Installed by (check one): |
| (
) Homeowner |
(
) Plumber |
(
) Other (specify) __________________________________ |
|
|
How did you hear about this program? (check all that apply):
|
| (
) Plumber |
(
) City Representative |
(
) Newspaper
Article |
| (
) Melbourne Messenger News Article |
(
) Radio or TV |
(
) Other (specify) |
|
| Do you have an irrigation system at your home?:
(
) Yes (
) No |
| If yes, is the water source for your irrigation
system (check one) |
| (
) well water |
(
) reclaimed
water |
(
) City water |
| (
) Other (please
explain) |
|
| |
| I have read and understand the toilet rebate policy requirements as stated in the
attached instruction sheet. I understand that in order to receive the rebate, I must
dispose of any replaced toilets so that they cannot reused. I also understand that an
inspection of the installed toilet may be required prior to rebate approval.
Please make sure the original receipt for the purchase of your toilet
is attached to this application. |
|
__________________________________________
Applicant’s Signature
|
_________________________
Date |
|
City Use Only |
|
|
|
|
Application # ____________________
|
Date application received:_________________ |
| Purchase Price of New Toilet: _______________________________________________________ |
| Original Receipt Included? (
) Yes (
) No |
|
| Inspection Date _________________ |
Inspector
______________________________________ |
| Comments____________________________________________________________________ |
|
Mail completed form to:
City of Melbourne, Environmental Community Outreach Div.,
2885 Harper
Road, Melbourne, FL 32904
|
