WaterStar rebates verification of purchase form

Applicant information

Unique application ID *
Business name *
IRWD account # (please separate multiple account numbers by commas) *
Primary street address
Building/unit number
ZIP code
Contact person – first name
Contact person – last name
Contact e-mail *
Phone number *

Device information

Model
Reserved quantity
Purchased quantity
Gallons per flush
Purchase price
Purchase date

Attachments

Attach W-9
Maximum file size: 8 MB