High-Efficiency Toilet Upgrade Application Step 1 of 10 - High-Efficiency Toilet Upgrade Program Application Qualifications 10% Step 1: QualificationsIn order to qualify for a high efficiency toilet through our program, you must confirm that you meet all of the following criteria: I have NOT have received a toilet through this program from Resource Central at any time previously. (Will be verified.)* I am replacing a toilet at a residence that receives water from the cities of Boulder, Erie, Lafayette, or Longmont.* I am replacing a toilet that uses MORE than 1.28 gallons per flush.* I am replacing only one toilet per water account number.* I will ensure that my space meets the toilet measurement specifications detailed in this form.* I understand that if I request Resource Central to install the toilet for me, the owner of the property must sign the Liability Waiver prior to installation.* I have read the Refund Policy here.* If you do not meet ALL of these qualifications, unfortunately you are not eligible for the 2018 Flush for the Future program. You may still purchase a Niagara Stealth toilet at a competitive retail price at Resource Central located at 6400 Arapahoe Road in Boulder. Step 2: Contact InformationName* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Water Provider (will be verified)*--- SELECT ONE ---BoulderErieLongmontLafayetteIf you cannot select your water provider, we are sold out in your area. If your water provider is not listed, this program is not currently offered in your area. DO NOT SELECT ANOTHER WATER PROVIDER. If your water provider is sold out, you may add yourself to our notification list, and we will contact you if more toilets become available in 2018. Water Account Number (as listed on your water bill)*We use this to verify your Water Provider. Phone*Email Updates Yes, I’d like to be added to the eNews mailing list where I can learn about how to put conservation into action in my own life and find out about other exciting conservation opportunities! Step 3: Survey Questions These survey questions have been included in order to provide your water provider and Resource Central with better information on the demographics of the participants in this program. Please answer the questions honestly. Resource Central guarantees that your responses will not be associated with your personal information, nor will they impact your eligibility for this program. Only anonymous, aggregated data summaries of your answer to these questions will be used in any reporting or assessment of the responses. Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?*YesNoWhat is your total annual household income before taxes?*Household = All full-time residents. Please combine if applicable.Less than $25,000$25,000 to $49,999$50,000 to $99,999$100,000 to $149,999$150,000 to $249,999More than $250,000Prefer not to answerHow many full time year-round residents live in your household?*123456 or more Step 4: Self or Tech InstallDo you want to install the toilet yourself or have our technicians install it for you?*Self-Install — $75.00 You must be available to pick up the new toilet and drop off your old toilet during one of our Toilet Exchange Events at Resource Central (6400 Arapahoe Road in Boulder). Next available Exchange Event is Sept 28th and 29th. We will contact you with details closer to the date. Includes:Niagara Stealth Toilet, toilet seat and wax ringRecycling of old toilet porcelain required at your Toilet Exchange EventTechnician Install — $175.00 Includes:Installation appointment with our trained techniciansNiagara Stealth Toilet, toilet seat and wax ringRemoval and recycling of old toiletSelf-Install Toilet Exchange Events will be:*--- SELECT ---TBD - Late October or NovemberNone of these dates work for meIf you are not available for any of our Toilet Exchange Events but would still like to participate in this program, you may select the Technician Install. We are happy to answer any questions at 303-999-3824 or water@resourcecentral.org. I understand that the Liability Waiver must be signed by the homeowner before or at the time of the installation appointment.* I understand an adult must be present for the full duration of the installation appointment.* Step 5: Toilet ClearanceMeasure from the floor to any shelf or other obstruction above the tank of your current toilet as indicated by the green line. Select the appropriate option below.* The Niagara Stealth toilet features an elegant silver flush button on top of the tank. You need to have at least 36 inches of vertical space for this toilet. Note: This is a critical measurement to ensure the Niagara Stealth toilet will fit in the intended space. Customers will not be eligible for a full refund if the new toilet does not fit. Please refer to the Refund Policy here. No shelf/obstruction exists above my toilet.I have at least 36 inches of vertical space.I have less than 36 inches of vertical space.The Niagara Stealth toilet will not fit in this space. Choose a different bathroom or move the obstruction. Step 6: Gallons Per Flush (GPF)Examine your toilet to find a marking that indicates the Gallons Per Flush (GPF). Select the appropriate option below.* The program goal is to conserve water, so existing efficient toilets are not eligible for replacement. Your current toilet must use more than 1.28 gallons per flush to qualify. If you have a dual flush toilet, please take the average of the two flush volumes as your single GPF number. Note: This is a critical step in verifying your eligibility for the program. Customers will not be eligible for a full refund if the existing toilet uses 1.28 GPF or less. Please refer to the Refund Policy here. My toilet uses more than 1.28 GPF.I don't see any GPF markings on my toilet.My toilet uses 1.28 GPF or less.Unfortunately, you do not qualify for a new toilet through this program, but the good news is that you already have an efficient toilet! Step 7: Toilet BoltsCheck your current toilet bolts (you may need to remove a small cap that often covers the bolts on either side of the toilet), and select the appropriate option below.* Note: This is a critical step in verifying your eligibility for the program. Customers will not be eligible for a full refund if proper hardware is not currently installed. Please refer to the Refund Policy here. The bolt threads are visible.The bolt head is visible.You may not have the appropriate hardware required to install a new toilet. You may need to purchase and install a flange before installing your new toilet.Unfortunately, you do not qualify for a Technician Install. You can go back to Step 4 and choose to receive a toilet through the Self-Install option. Step 8: Rough-In Measurement & Toilet ShapeMeasure the rough-in of your current toilet. (See the illustration for instruction on how to take this measurement.) Select the appropriate option below.* Note: This is a critical step in verifying your eligibility for the program. Customers will not be eligible for a full refund if the toilet does not fit because the rough-in was mis-measured. Please refer to the Refund Policy here. My rough-in is 11.75 inches or greater.My rough-in is at least 9.75 inches but less than 11.75 inches.My rough-in is less than 9.75 inches.Unfortunately the Stealth Toilet won’t fit in your space, but we may have other programs to help you save water. Learn more about our other water-saving programs in your area.You qualify for a Round or Elongated toilet bowl. Please review the measurements of each toilet, and measure your space carefully to ensure the toilet you choose fits. Select which you prefer.* Note: Customers will not be eligible for a full refund if the toilet does not fit. Please refer to the Refund Policy here. Round Best in smaller bathrooms/spacesShorter and therefore better for shorter individualsConsidered more standard for a home toiletElongated Larger so requires more spaceTaller and therefore can be more comfortable for certain peopleADA compliantYou qualify for a Round toilet bowl. This toilet is designed for spaces with smaller rough-ins. Please only select this option if your toilet’s rough-in measures 9.75” - 11.75”. Step 9: ReviewCongrats! You chose the Self Install option. We will email detailed information as your Toilet Exchange Event approaches. Congrats! You chose the Technician Install option. We will be in contact in a few weeks to to schedule an installation appointment once we have availability in our technicians' schedules.Please review your order details below and proceed to the next page to enter your payment information. In order to qualify for a high efficiency toilet through our program, you have confirmed that you meet all of the following criteria: {High Efficiency Toilet Program Qualification Confirmation:63} Name: {Name (First):1.3} {Name (Last):1.6} Email: {Email:3}{Email Updates:6} Phone: {Phone:4} Installation Address: {Address (Street Address):2.1}, {Address (Address Line 2):2.2} {Address (City):2.3}, {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Community: {Community (will be verified):5} Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?: {Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?:67} What is your total annual household income before taxes? {What is your total annual household income before taxes?:68} How many full time year-round residents live in your household? {How many full time year-round residents live in your household?:69} Installation Preferences: {Do you want to install the toilet yourself, or have our technician install it for you?:26} {Self-Install Pick-Up Days will be::40} Toilet Measurements: {Measure Vertical Space:10} {Check Gallons Per Flush:44} {Check Toilet Bolts:15} {Measure Rough-in:12} Toilet Selection: {Qualify for Round or Elongated:13}{Qualify for 10-inch Round ONLY:70}Confirmation of Installation Requirements: {Installation Requirements:62} I have reviewed the information above and confirm that I entered all of this information accurately.* Step 10: PaymentPlease confirm the following: I am purchasing this toilet to replace an existing inefficient toilet and understand that is a requirement of this program. I will exchange my current toilet for this new one.* I have read and understand the Refund Policy.* {pricing_fields}Installation Address: {Address (Street Address):2.1} {Address (Address Line 2):2.2} {Address (City):2.3}, {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Is your billing address different?*Yes, I need to enter a different billing addressNo, my billing address is the sameBilling Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Credit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Please click the submit button only once to prevent processing errors.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. * Asterisks in this application form indicate that the question is mandatory.
