Black Hills On-Site Solar Power Program

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* Indicates required field

Service Account Number at Installation Address:

First Name:

Last Name:

Installation Address:

City:

State:

Zip:

Daytime Telephone:

Email Address:

Mailing Address (if different from above):

Mailing City:

Mailing State:

Mailing Zip:

Equipment Purchase Date:

PV Manufacturer:

PV Model Number:

Module Warranty (years):

Nameplate Rating of Module:

Number of Modules in Array:

Array Orientation (compass direction the array faces, in degrees):

Array Tilt Angle (in degrees, horizontal=0, vertical=90):

Inverter Manufacturer:

Inverter Model Number:

Inverter Warranty (years):

Number of Inverters:

Other Information:
(If new construction, enter sq. footage here.)

Will this be installed by the customer?

Yes

If no, provide contractor information.

Contractor Name:

Contractor Address:

Contractor City:

Contractor State:

Contractor Zip:

Contractor Phone:

Is this a third party developer owned system?

Yes No

Developer/Owner Name:
Developer/Owner Address:

Developer/Owner City:
Developer/Owner State:
Developer/Owner Zip:
Is third-party payee same as the developer/owner listed above?	Yes No

I authorize rebate payment to a third-party described below:	Yes No
Third Party Payee Name:
Third Party Payee Address:

Third Party Payee City:
Third Party Payee State:
Third Party Payee Zip:

Check this box to verify you have read and understand the program rules:

Yes, I have read the program rules

Check this box to indicate you have read and acknowledge the NABCEP requirements.

Yes

I understand that a deposit and a one- line diagram is required with my application and must be received within 5 calendar days of the application submission. See Deposit Policy for more information:

Yes, I agree

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If you are aware of downed power lines or have another electrical or gas emergency, please call our emergency number at 1-800-694-8989.