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2. You can receive up to a $400 rebate for a qualifying home energy audit
4. First Name*
5. Last Name*
7. Roeland Park Address*
9. Phone Number*
10. Email Address*
12. Mailing address, if different from above:
14. Address
16. City
17. State
18. Zip Code
20. How did you hear about this program?
22. Name of energy auditor:*
23. Date of audit:*
    Date of audit:
24. List of approved energy auditors:
    Energy Auditors
26. Upload Invoice*
27. Upload Audit report*
28. Other Upload
29. Other Upload

31. Applicant Agreement I certify that I live within Roeland Park, KS. I understand that the City of Roeland Park, KS does not guarantee the results of the audit. The undersigned further agrees to defend, indemnify and hold harmless the City of Roeland Park, KS including their employees, from and against any and all loss, damage, expense, claims suits and liability, including attorney fees arising out of or in any way connected with the audit. Applicant has read, understands and agrees to the terms and conditions listed on the Home Energy Audit Incentive application. The City of Roeland Park, KS reserves the right to change the terms of the incentive offer at any time. I have read, understand, and agree to the terms and conditions of this rebate program.

33. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature*
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field