Electric Vehicle Charging Incentive Application 2018 EV Commercial and Municipal Charging Incentive Application Section A: MEMBER INFORMATIONBusiness Name (as it appears on NHEC bill) * RequiredContact Person * Required First Last Title * RequiredMailing Address * Required 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 Phone * RequiredEmail * Required Member Account Number * RequiredMeter Number: * RequiredHow many hours per week is your business open to the public?Additional InformationHow did you hear about this program?Select oneAdvertisement inserted in my billCar dealershipContractorEmailInternet search (Google, Bing, Yahoo)Event (car show, tradeshow)Friend/ColleagueNHEC newsletterNHEC representativeNewspaperPostal mailSocial media (Facebook, Twitter, LinkedIn)OtherPlease tell us how you first heard about the charger incentive program.Section B: INSTALLER INFORMATIONInstaller's Name * RequiredContact Person * Required First Last Mailing Address * Required 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 Email * Required Phone * RequiredSection C: INSTALLATION DETAILSPlease upload site diagram where EV charger will be installed * Required File uploadProject Address ( where EV will be installed) * Required 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 Proposed Project Start Date - must be mm/dd/yyyy format Circuit Voltage serving chargerCircuit breaker poles (2/P, 3/P)Installation Validation * Required The system has been installed as listed in the Incentive Application and in compliance with all applicable requirements of the local codes authority, State of NH codes and National codes Installation of the system is complete and the system is operating as designed The final contract signed by the member and installer with final cost is included with this form If self-installed, include all documentation that the installed system has been inspected by a local building code official or licensed electrician Please upload all installation and inspection documentation File uploadSection D: SignatureTerms and Conditions * Required Yes I have read and understood all materials, including the Terms and ConditionsMember Signature * RequiredDate - must be mm/dd/yyyy format * Required EmailThis field is for validation purposes and should be left unchanged.