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2. Name
3. Email Address*
5. Address
7. Address 2
9. City
10. State
11. Zip Code
13. Daytime Phone Number
14. Evening Phone Number
16. Program Options

    There are two options to participate in the EcoSmart Choice Program:

18. Option 1

    Select from the following participation levels with the associated amounts to be added to your monthly bill:

    1. 100% participation (adds $0.004 per kWh)
    2. 75% participation (adds $0.003 per kWh)
    3. 50% participation (adds $0.002 per kWh)
    4. 25% participation (adds 0.001 per kWh)
20. Option 2: Contribute a fixed dollar amount per month.

    Please indicate the monthly dollar amount you'd like added to your monthly bill in the space above.

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field