Energy Efficiency Fund

The fields preceded by an asterisk* are mandatory

Gaz Métro Account No. (if available):

Applicant's identification

*	Contact name :		*	E-mail :
*	Applicant's email address (for receipt notification)

Name of organization:

Person in charge of project:

Telephone:

*E-mail:

Type of organization:

Mission of organization:

Clientele served:

Address of building:

Municipality:

* Postal code:

Year of construction:

Number of rental units or offices:

Number of floors:

Total floor area:

ft²

Are there other sources of heating other than natural gas in the building?

yes no

If yes, provide the following details :

* Source of energy for heating
*Area covered by heating appliances	%
*Total capacity of heating appliances

Date work expected to begin: (DD-MM-YYYY)

Date work expected to be completed: (DD-MM-YYYY)

Type of water heater:

Type of unity installed :

or
Other model, specify :

The EFF may contact you as part of the evaluation of the program for the installation of drain water heat recovery systems.

I declare that the information provided in support of my request to participate in this program is exact and complete.

Date: 04-02-2012

PS 150 – drain water heat recovery systems form – v1
Last update: March 1^st, 2011