ENERGY STAR® Induction Cooktop and Range Incentive

Note: Incentive must be redeemed within 6 months of purchase date. Your purchase receipt must accompany this form.

Induction Cooktop and Range Incentive

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Account Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Location of Install(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Brand Name(Required)

Model Number(Required)

Purchased At

Purchase Receipt(Required)

Your purchase receipt must accompany this form.

Max. file size: 50 MB.

Member Signature (Full Name)(Required)

This form is also available to download, print, and return: Induction Cooktop and Range Incentive Application (PDF)