Electric Vehicle Pre-Sales Form 2018 Electric Vehicle Pre-Vehicle Purchase Form Section A: MEMBER INFORMATIONMember Name (as it appears on NHEC bill)* NHEC Account Number* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone #*Email* How did you hear about this rebate?Select oneAdvertisement inserted in my billCar dealershipEmailEV event/tradeshowInternet search (Google, Bing, Yahoo)Friend/ColleagueNHEC newsletterNHEC representativeNewspaperPostal mailSocial media (Facebook, Twitter, LinkedIn)OtherSection B: Electric Vehicle InformationMy Electric Vehicle will bePurchasedLeasedElectric Vehicle ClassificationPlug-in Electric Vehicle (PHEV)Battery Electric Vehicle (BEV)Vehicle Make Vehicle Model Vehicle Year VIN # (used model only): Section C: SignaturesI have read and understood all materials, including the Terms and Conditions* Yes Read the terms and conditions by clicking here.Member Signature* Date* MM slash DD slash YYYY Δ