Energize CT Pre-Approval Request
Please fill out one form per installation address. You are able to add up to 3 different products per form. Any additional products should be entered into the comments section at the end.
The pre-approval request form is not intended to act as a product eligibility check. Please confirm that the product appears on the required QPL before submitting a pre-approval request.
Please contact Madison at (510) 482-4420 x718 with any questions.
* Required
Email address
*
Your email
Requester First Name
*
Your answer
Requester Last Name
*
Your answer
Distributor Business Name
*
Your answer
Customer Installation Information
Customer Business Name
*
Your answer
Street Address
*
Your answer
Unit Number
Your answer
City
*
Your answer
Zip Code
*
Your answer
Customer Contact Full Name
Your answer
Customer Contact Phone
Your answer
Customer Contact Email Address
Your answer
Is this for a new construction project?
*
Yes
No
Approx Sq. Ft.
Your answer
Business Segment
Choose
College & University
Grocery/Food Sales
Hospital
Industrial/Manufacturing
K-12 School
Lodging
Medical Office
Office Building
Other
Parking Garages
Police/Fire Station (24 hr)
Restaurant/Food Service
Retail
Warehouse and Storage
Product Information #1
Product Type #1
*
Choose
LED A-line 40/60 W
LED A-line 75/100W
LED PAR30/BR30
LED PAR38/BR40
LED PAR16/MR16/GU10
LED Decorative Lamps
LED G24
LED G23
LED PAR20/BR20
LED Retrofit Kit, <25W
LED Retrofit Kit >25W
TLED - 2 ft
TLED - 4 ft
TLED - 8 ft
TLED - U-bend
T5 LED
Stairwell LED Kit, low-output with sensor
Stairwell LED Kit, mid-output with sensor
LED 1x4 Troffer Standard
LED 1x4 Troffer Premium
LED 2x2 Troffer Standard
LED 2x2 Troffer Premium
LED 2x4 Troffer Standard
LED 2x4 Troffer Premium
LED Linear Ambient
LED High/Low Bay (20-99 W)
LED High/Low Bay (100-199 W)
LED High/Low Bay (≥200W)
Mogul Interior Low Bay
Mogul Interior High Bay
Parking Garage 20-99W Standard
Parking Garage 20-99W Premium
Parking Garage 100-199W Standard
Parking Garage 100-199W Premium
LED Exterior Fixture (20-99 W)
LED Exterior Fixture (<20 W)
LED Exterior Fixture (100-199 W)
LED Exterior Fixture >=200W
Mogul Exterior 175W equivelent
Mogul Exterior 250W equivalent
Mogul Exterior 400W equivalent
Manufacturer #1
*
Your answer
Model #1
*
Your answer
Quantity Requested #1
*
Your answer
Estimated Install Date #1
*
MM
/
DD
/
YYYY
Product Notes #1
Your answer
Add another product for this installation address?
*
Yes
No
Next
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