Referral Form

Discount Coupon

10% Off Any
Hearth Product

Your Name: __________________________________________

Account#: ______________________Phone #: _____________

Mailing Address: _______________________________________

(Street) (City, State, Zip)

Delivery Address: ______________________________________

(Street) (City, State, Zip)

Item Purchased: _______________________________________

Purchase Price: ___________________/____________________

(Before Discount) (After Discount)

Print this form and present it to a Blue Ridge Energies showroom sales representative to receive your 10% discount on any hearth product available through Blue Ridge Energies.

Discount Terms and Conditions

ALL Blue Ridge Energies' customers can participate! Offer is limited to one discount coupon per family. Promotion good through December 31, 2007.