VENDOR / RETAILER INFORMATION
Name of Vendor/Retailer:
Website:
Mailing Address:
City/State/ZIP:
Check all ENERGY STAR® appliances sold in all stores:
Refrigerators Clothes Washers Dishwasher High-Efficiency Gas Storage Water Heater Electric Heat Pump Water Heater
VENDOR / RETAILER POINT OF CONTACT
First Name:
Last Name:
Job Title:
Phone Number:
Email:
Check this box if vendor/retailer has more thean one retail location
PARTICIPANT EXPECTATIONS
Participating vendors/retailers must agree to comply with all of the following conditions at all storefront locations:  *All boxes must be checked to participate with the Ohio Department of Development:
In Store:	Make rebate forms available to consumers during the Program’s effective dates. Promote the Program to consumers via in-store signage, flyers, advertisements. Display a printed, legible copy of the current list of United States Department of Energy (DOE) approved ENERGY STAR® appliances (refrigerators, clothes washers, dishwashers, high-efficiency gas storage water heaters, electric heat pump water heater) eligible for rebates. Properly identify, with a visible marker, showroom appliances that are eligible for a rebate, including the rebate value. Provide consumers sales receipts as proof of purchase.
	Store Staff: Provide store staff with information on the Ohio Energy Efficient Appliance Rebate Program. Have store staff remind consumers that, in order to receive a rebate, consumers must purchase a new appliance for the purpose of replacing an old appliance. Have store staff verify with the consumer that the product being purchased is a qualified model eligible for a rebate. Have store staff inform consumers of available delivery and haul away services provided by vendor/retailer, and assist consumers with arrangement of haul-away of old appliance.
Marketing and Outreach:	Provide a link on vendor/retailer’s website to the Ohio Energy Efficient Appliance Rebate Program website – www.OhioApplianceRebate.com. Include the following information on all marketing material: Program Dates Starting date - Late March 2010 Website address – www.OhioApplianceRebate.com Correct title of the program – Ohio Energy Efficient Appliance Rebate Program Ohio Energy Efficient Appliance Rebate Program Logo List of five appliance types (in vendor/retailer's inventory) that are eligible for rebate with rebate values: Refrigerators - $100 Clothes washers - $150 Dishwashers - $100 High-efficiency gas storage water heater - $100 Electric heat pump water heater - $250
Delivery and Haul-Away:	Provide the consumers the option for delivery and haul-away services for purchase of qualified appliances bought by the consumer during the Program effective dates. Provide consumers receipts for haul-away services at the time of purchase or at time of delivery and haul-away of old, used appliance.
Recycling /Disposal:	Haul-away 100% of used appliances replaced as part of the Ohio Energy Efficient Appliance Rebate Program, and ensure they are recycled or disposed of properly. Old appliances must be de-manufactured so they are rendered permanently inoperable and processed through a recycling or disposal facility. All hazardous materials are handled in accordance with Federal, State, and Local laws. All recyclable material are sorted and reprocessed into raw materials for future use.
Reporting	Report to the Ohio Department of Development, the number and type of appliances collected, hauled away, and recycled within the State of Ohio, during the program start and end date. – Reports should be sent within 20 days after the Program end date. Quantify and report to the Ohio Department of Development, overall in-kind service contributions. – Reports should be sent within 20 days after the Program end date.
RECYCLING / DISPOSAL DETAILS In the space provided below, briefly describe the details of the vendor/retailer’s recycling program. Include the name(s) of the recycling facility the vendor/retailer plans to work with, how the items will be stored, and the frequency of pick-up/haul-away with the recycling facility(ies). (500 word limit)
I certify that I am an officer or employee of the identified vendor/retailer with the title set forth below, and I am authorized to bind the vendor/retailer to the terms of this Agreement. The information provided in this Agreement is accurate and complete.
First Name:
Last Name:
Job Title:
Phone Number:
Email:
Date: