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Customer Information Form – Berko Toe-Space Heater Program
Important Note: Not all Berko Toe-Space Heaters are involved in this program. ONLY those models manufactured before February 15, 1985, as shown in the How To Check Your Heater instructions, are eligible for the rebate or discount program.
Please complete this form and return to the address shown with the required part(s) from your old heater(s) to be eligible for the rebate or discount on the purchase of a new heater (or heaters). Remember, we must receive the plug from each heater with this form for your request to be considered.
Applying for: $25 Rebate Discount on replacement heater(s) & labor allowance

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Name: ______________________ Home Phone: ____ - ________ Other Phone: ____ - ________
Address: ________________________ Apt #:_____ City: _______________State: ___ Zip: _______
Heater Information: Total number of affected TS heaters in my home ___________
Heater #1:
Heater Location: Kitchen Bathroom Below Cabinets at floor level Other _____________
Nameplate Name: Berko Electric Emerson Other __________________________
Heater Model (Shown on Nameplate) ________________________ Date Code Stamp __________
Does heater have thermal fuse ? Yes No Supply Voltage 120 Vac 240 Vac
Type thermostat provided Wall (line voltage) Heater (built-in) Other _______________
Comments: ______________________________________________________________________

Heater #2:
Heater Location: Kitchen Bathroom Below Cabinets at floor level Other ____________
Nameplate Name: Berko Electric Emerson Other __________________________
Heater Model (Shown on Nameplate) ________________________ Date Code Stamp __________
Does heater have thermal fuse ? Yes No Supply Voltage 120 Vac 240 Vac
Type thermostat provided Wall (line voltage) Heater (built-in) Other _______________
Comments: ______________________________________________________________________

As a condition of my completion of this form and submitting for either the Rebate or Replacement Heater Discount, I understand and agree to disable each affected Berko Toe-Space heater in my home so it cannot be used again.
Customer Signature: ___________________________________ Date: ______________________

CUSTFORM – Rev C

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