Date: *

MM

DD

YYYY

Name: *

First Name

Last Name

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone: *

(###)

###

####

Water Heater Size *

50 Gallon

85 Gallon

100 Gallon

Is your water heater a replacement or for new construction? *

A replacement

For new construction

Was your old water heater gas or electric?

Gas

Electric

What size was your old water heater?

50 Gallon

85 Gallon

100 Gallon

Did you have a control on your old water heater?

Yes

No

Acknowledgement Agreement *

By checking this box I acknowledge that I have read and understand the terms and conditions of the water heater control program at BENCO Electric Cooperative. I agree to have a radio receiver installed on my water heater for the purpose of controlling it according to BENCO's load management guidelines. The water heater is to remain controlled and in BENCO's service territory for the life of the water heater. I understand that BENCO reserves the right to inspect the installation and to verify compliance with the requirements of the control program.

Yes