Ductless ASHP Rebate

Member information
Name on account*

First NameLast Name
Connexus account number
Phone number
Email address*
Installation address*

Street Address

Street Address Line 2

CityState

Zip Code
Equipment information
Manufacturer*
Model #*
Serial number*
SEER/SEER2 rating*
Warning: Ductless ASHP SEER/SEER2 rating must be greater than 17.2.
EER/EER2 Rating*
Warning: Ductless ASHP EER/EER2 rating must be greater than 11.7.
HSPF2 Rating*
Warning: Ductless HSPF2 rating must be greater than 8.5.
AHRI certificate number*
Date of installation*

MonthDayYear
Date
Previous primary heating source*

Natural gasPropaneFuel oilElectricOtherNone
Furnace replaced

YesNo
Previous cooling source

ACASHPNone
Attach all itemized invoices/receipts, specification sheet and AHRI Certificate associated with the purchase/installation of the project.*

Cancelof
Contractor information
Installation*

Self-installContractor
Company*
Company address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Please enter a valid phone number.
Member hereby certifies that 1) the member is solely responsible for the accuracy of the application information; 2) all installation is complete and operational prior to submitting this application; 3) acknowledges that nothing contained in the application shall impose any liability on Connexus Energy for any work performed or information presented by the member’s engineer, contractor, or vendor; and 4) Connexus reserves the right to verify performed work.
Signature*

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Please verify that you are human*
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Member information

Equipment information

Contractor information