Home Security Rebate Program
Jan 05, 2018
submission
#116
Application Form
Applicant Information
| Name | --- |
| Home address (City, State, Zip Code) | --- |
| Type of phone | --- |
| Email address | --- |
Demographic Information
| Applicant status | Property Owner |
| Applicant age | 41-64 years old |
| Highest educational level | Bachelor's Degree or above |
| Household size | 2 persons |
| Household income | Over $100,000 |
Tell Us About Your Purchase
| What did you buy? | Security camera, Motion-sensor light / timer |
| How much did you spend? | $270.32 |
| Copy of receipt / invoice | --- |
We Need Your John (or Jane) Hancock!
| I agree to the above statement and affirm the validity of everything I have entered in this application. | --- |