Please enable JavaScript in your browser to complete this form.Name *FirstLastOrganization name (if applicable)Mailing address and contact infoTerritory/province *Northwest TerritoriesAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonCommunity *AklavikBehchokǫ̀Colville LakeDettahDélı̨nęEnterpriseFort Good HopeFort LiardFort McPhersonFort ProvidenceFort ResolutionFort SimpsonFort SmithGamètìHay RiverInuvikJean Marie RiverKakisaKátł'odeecheŁutsel K’eNahanni ButteNdilǫNorman WellsPaulatukSachs HarbourSambaa K’eTsiigehtchicTuktoyaktukTulitaUlukhaktokWekweètìWhatìWrigleyYellowknifeCommunity *Mailing address *Postal Code *Phone *Email *Installation infoIs the product installed at the same place as your mailing address? *YesNoSorry, to be eligible for a rebate, your products must be installed in the Northwest Territories. Please contact us if you have any questions. Due to some website quirks, the “Submit” button is still at the bottom of this form. Feel free to ignore it—you don’t need to submit anything right now. But if you happen to click it, we’ll send you a friendly note confirming that your products aren’t eligible for a rebate. Community where the product was installed *Off-grid/remoteAklavikBehchokǫ̀Colville LakeDettahDélı̨nęEnterpriseFort Good HopeFort LiardFort McPhersonFort ProvidenceFort ResolutionFort SimpsonFort SmithGamètìHay RiverInuvikJean Marie RiverKakisaKátł'odeecheŁutsel K’eNahanni ButteNdilǫNorman WellsPaulatukSachs HarbourSambaa K’eTsiigehtchicTuktoyaktukTulitaUlukhaktokWekweètìWhatìWrigleyYellowknifeAddress where the product was installed *Postal code where the product was installed *Did you install your product at a seasonal home or cabin? *YesNoProductsWhat kinds of products did you buy?ENERGY STAR® certified domestic appliancesClothes washerRefrigeratorUpright or chest freezerVentless clothes dryerAll-in-one washer/ventless dryerWasher make/brand *Washer model number *How many washers did you buy? *Refrigerator make/brand *Refrigerator model number *How many refrigerators did you buy? *Are you replacing an old refrigerator? *YesNoRefrigerator disposal *I agree to take my old refrigerator to the appropriate place in the landfill for disposal.Required to qualify for a rebate.Freezer make/brand *Freezer model number *How many freezers did you buy? *Are you replacing an old freezer? *YesNoFreezer disposal *I agree to take my old freezer to the appropriate place in the landfill for disposal.Required to qualify for a rebate.Ventless dryer make/brand *Ventless dryer model number *How many ventless dryers did you buy? *All-in-one washer/ventless dryer make/brand *All-in-one washer/ventless dryer model number *How many all-in-one washers/ventless dryers did you buy? *Heating appliancesWood stove/pellet stoveWood stove or pellet stove? *Wood stovePellet stoveStove make/brand *Stove model *How many stoves did you buy? *Home upgradesDrain water heat recoveryProgrammable thermostatECM heating, circulating or domestic water pumpAutomated vehicle plug-in controllerDrain water heat recovery make/brand *Drain water heat recovery model number *How many drain water heat recovery units did you buy? *Thermostat make/brand *Thermostat model *How many thermostats did you buy? *Pump make/brand *Pump model number *How many pumps did you buy? *Automated vehicle plug-in controller make/brand *Automated vehicle plug-in controller model number *How many automated vehicle plug-in controllers did you buy? *Automated vehicle plug-in controller settings *My automated vehicle plug-in controller is programmed to the following settings. • No power to the system above −12°C for diesel vehicles or −17°C for gasoline vehicles (can be set lower). • Continuous, full power only below −35°C for all vehicles (can be set lower). • Intermittent or limited power between these temperatures.To qualify for a rebate, a controller must be programmed to these settings.LED lighting (only available in non-hydro communities)LED bulbs and tubesLighting make/brand *If you purchased more than one brand, enter all of the brand names.Lighting model number *If you purchased more than one model, enter all of the model numbers.How many bulbs or lights did you buy? *DocumentsAttach a copy of your receipt and other documents. The names on the receipts must match the name on this application form.Number of receipts to upload *12345678910Attach a copy of your receipt *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (2) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (3) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (4) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (5) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (6) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (7) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (8) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (9) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your receipt (10) *Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffIf your receipt does not have your address on it, please upload proof that you live in the NWT.Examples include a copy of a driver’s licence or utility bill. Please hide any unnecessary information, such as your licence number or billing history. Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffDo you have a photo of the EnerGuide card from your appliance, showing the ENERGY STAR logo?YesNoNumber of EnerGuide card photos to upload12345678910Attach a copy of your EnerGuide cardAllowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (2)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (3)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (4)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (5)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (6)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (7)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (8)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (9)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your EnerGuide card (10)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffDo you have a photo of your LED bulb or tube, or it's packaging?YesNoNumber of LED lighting photos to upload12345678910Attach a copy of your LED bulb or tube, or it's packagingAllowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (2)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (3)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (4)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (5)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (6)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (7)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (8)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (9)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAttach a copy of your LED bulb or tube, or it's packaging (10)Allowed file types: .pdf, .jpg, .jpeg, .png, .tif, .tiffAcknowledgement and consentTerms and conditions *I acknowledge that I have read and understood the terms and conditions of this form, and that the products I have purchased have been installed at the address listed above.Personal information *I consent to the collection and disclosure of my personal information for the purposes of delivering this program, as per the Consent to Collection and Disclosure of Personal Information policy below.Your participation in the Energy Efficiency Incentive Program (the “Program”) requires the Arctic Energy Alliance (“AEA”) to collect information from you, including your personal information. The AEA will collect your information, including your personal information, for the purpose of delivering the Program. All personal information collected from you by AEA is protected by the Personal Information Protection and Electronic Documents Act, SC 2000, c 5. The Program is delivered by the AEA pursuant to the terms of the contribution agreement between the AEA and the Government of the Northwest Territories (“GNWT”) (the “Contribution Agreement”). Under the terms of the Contribution Agreement, the AEA is obligated to disclose your information, including your personal information, to the GNWT or the Government of Canada (“Canada”), or both, from time-to-time for the purpose of reporting and the public release of Program statistical data. The collection and disclosure of your information, including your personal information, by the GNWT and Canada is subject to applicable territorial and federal privacy legislation, including the Access to Information and Protection of Privacy Act, SNWT 1994, c 20, and Privacy Act, RSC 1985, c P-21. By checking the box above you acknowledge that you have read this notice and that you consent to the collection of your information, including your personal information, by AEA and the disclosure of said information by AEA to the GNWT or Canada or both for the purpose of administering the Program. You further consent to the collection and disclosure of your information, including your personal information, by the GNWT and Canada for the purpose of reporting and the public release of Program statistical data.Submit your applicationSubmit
