DUAL FUEL EQUIPMENT ENROLLMENT FORM

Date:

MM

DD

YYYY

Name:

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Phone:

(###)

###

####

BENCO Account #:

Please list the equipment you would like enrolled in the program:

For example: Geo-Thermal Heat Pump, Air-Source Heat Pump, Water Heater, etc.

Acknowledgement Agreement

By checking this box I acknowledge that I have read and understand the terms and conditions of the dual fuel program at BENCO Electric Cooperative. I agree that appliances enrolled in the program will be controlled by BENCO. I agree to have an automatic back-up heating source.

Yes