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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. A  pplying for: $25 Rebate Discount on replacement heater(s) & labor allowancePlease Print ClearlyName: ______________________ Home Phone: ____ - ________ Other Phone: ____ - ________ Address: ________________________ Apt #:_____ City: _______________State: ___ Zip: _______ Heater Information: Total number of affected TS heaters in my home ___________ Heater #1: H  eater Location: Kitchen Bathroom Below Cabinets at floor level Other _____________ N ameplate Name: Berko Electric Emerson Other __________________________Heater Model (Shown on Nameplate) ________________________ Date Code Stamp __________ D oes heater have thermal fuse ? Yes No Supply Voltage 120 Vac 240 VacT ype thermostat provided Wall (line voltage) Heater (built-in) Other _______________Comments: ______________________________________________________________________ Heater #2: H eater Location: Kitchen Bathroom Below Cabinets at floor level Other ____________ N ameplate Name: Berko Electric Emerson Other __________________________Heater Model (Shown on Nameplate) ________________________ Date Code Stamp __________ D oes heater have thermal fuse ? Yes No Supply Voltage 120 Vac 240 VacT ype 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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