2. Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Account Number*
11. Phone Number*
13. Number of Green Switch Blocks*

    1. 200 kilowatt-hours: $2
    2. 400 kilowatt-hours: $4
    3. 600 kilowatt-hours: $6
    4. 800 kilowatt-hours: $8
    5. 1000 kilowatt-hours: $10
    6. Other Amount
15. Please designate the number of Green Switch Blocks you would like to purchase if option is not listed above.
17. Signature*
18. Date*
    Date
20. Please complete, print, and sign this form and submit to the City of Alcoa via fax or email.
    Fax: 865-380-4723 Email: businessoffice@cityofalcoa-tn.gov
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21. Print Only

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