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Port Colborne Residential Ultra Low Flow Toilet Rebate Program Application Form

First Name

Last Name

Phone Number

Mailing Address

City/Town

Postal Code

Address of Toilet Installation

City/Town

Postal Code

Are you on a private well?

Yes

Number of Toilets at Address

Number of Persons at Address

Manufacture

Model Name

Flush Capacity(s)

Purchase Date (must be after January 1, 2019)

Purchase Location (store)

Install Date

Who did the installation?

Installed by a Plumber/Contractor

Did it Myself

Please upload an image of your receipt

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