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2. Review requirements and information at
   Programmable Thermostat Rebate

   A rebate of up to $100 can be used to cover the cost of the thermostat or the expense of installing it. * Must meet requirements to qualify for the rebate.

   
   

4. First Name*
5. Last Name*
7. Service Address*
8. Service Address Zip Code*
10. Mailing Address*
    Put "Same" if your service address is the same as your mailing address.
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Gas Account Number
18. Email*
20. Place of Purchase
21. Date of Purchase*
    Date of Purchase
22. Cost of Purchase / Installation*
24. Thermostat Brand and Model
25. Property Type*
    -- Select One --ResidentialCommercial
26. Method of Rebate Payment*
    -- Select One --CheckCredit Account

    Note: Checks can only be sent to the name listed under the utility account or the owner listed via the assessor database.

28. A copy of your purchase receipt and/or invoice for installation must accompany this form.*
30. By checking each box you certify the following: *

    1. I am a Charlottesville Gas customer
    2. My Charlottesville Gas account is in good standing
    3. I use natural gas for home heating
    4. I have installed a programmable thermostat on my Charlottesville Gas heated home

    You must check ALL boxes to be considered eligible for this rebate. NOTE: This rebate does not apply to new construction.

32. Name*
    Electronic Signature- By adding your name here you agree that everything above is correct and submitted by you.
33. Today's Date*
    Today's Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field