WaterStar Rebates Verification of Purchase Form

Applicant information

Unique application ID(*)

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Business Name(*)

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IRWD Account # (please separate multiple account numbers by commas)(*)

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Primary Street Address(*)

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Building/Unit Number(*)

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Zip Code(*)

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Contact Person – First Name(*)

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Contact Person – Last Name(*)

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Contact E-mail(*)

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Phone Number(*)

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Device information

Model

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Reserved quantity

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Purchased quantity

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Gallons per flush

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Purchase price

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Purchase date

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Attachments

W-9(*)

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(*)

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customer care

customer care