2017 NEC VHD Incentive Form

Section A: CUSTOMER INFORMATION

Customer Name *

First Last

Facility Address *

Street Address Address Line 2 City State ZIP Code

Is this the mailing address? *

Yes
No

Mailing Address *

Street Address Address Line 2 City State ZIP Code

Electric Account Number *

Rate *

Application Number

Service Location Identification

Email *

Contact Person *

First Last

Title *

Phone *

Incorporated *

Yes
No
Exempt

Incentive Payment Preference *

Check
Bill Credit
Pay Contractor

Please Assign Payment to Contractor *

Customer Signature

Additional Information

Section B: CONTRACTOR INFORMATION

Contact Person *

First Last

Contact Title *

Contractor Name *

Contact Person Signature

Mailing Address *

Street Address Address Line 2 City State ZIP Code

Email *

Phone *

Additional Info

Incorporated *

Yes
No
Exempt

Section C: DOCUMENT APPROVALS

PRE-INSTALLATION INSPECTION

Utility Signature

Date

PRE-APPROVAL OFFER

Technical Review - Utility Signature

Date

Utility Signature

Date

Amount of Incentive Offer

Offer Valid Through

By signing and dating below, customer accepts this Incentive offer and agrees to the Utility Terms and Conditions available from your Utility. Pursuant to a Commission order, customers also agree that the utility alone may capture all kW and kWh savings and any ISO-NE capacity payments resulting from this energy efficiency project. This agreement is contingent upon continued approval and authorization by the Commission to recover said amounts from the System Benefits Charge. The Incentive, in conjunction with all other sources of funding, cannot exceed the total project cost.

Customer Signature

Date

Post-Installation Inspection

Official NHEC Use Only

Utility Signature

Date

Customer Signature

Date

Total Project Cost

Amount of Incentive

Management Approval

Date

2017 NEC VHD Incentive Form

NEC VFD Incentive

Step 1 of 2

Section A: CUSTOMER INFORMATION

Section B: CONTRACTOR INFORMATION

Section C: DOCUMENT APPROVALS

Post-Installation Inspection

Incentive Worksheet

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Incentive Total