DEDHAM-WESTWOOD WATER DISTRICT

WATERLESS URINAL

NEW OR REPLACEMENT PROGRAM

APPLICATION FOR REBATE

Name _____________________________________ Account No. _____________

Property Address______________________________________________________

Mailing Address (if different)__________________________________________________

Phone No.___________________________

I hereby certify that I am a customer of the Dedham-Westwood Water District (the District). In order to be eligible for this program, I understand that my account must be current.

I agree to indemnify and hold harmless and defend the District and all of its commissioners, officers, agents, employees or authorized agents, employees or authorized representatives from any claims, suits, actions, losses or liability of every kind, nature and description, including but not limited to, the delivery, installation, product malfunction, plumbing malfunction, maintenance or use of appliances purchased through this program.

I will also allow the District to inspect the installation of the urinal(s) within six months of installation. If access for an inspection is denied, the District will not grant the rebate.

________________________________________________ _______________

Signature Date