Electric Vehicle Rebate Application Electric Vehicle Rebate Application EV Rebate Application 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* Section B: Electric Vehicle InformationMy Electric Vehicle wasPurchasedLeasedElectric Vehicle ClassificationPlug-in Hybrid Electric Vehicle (PHEV)Battery Electric Vehicle (BEV)Electric Motorcycle (EM)Vehicle Make Vehicle Model Vehicle Year VIN of purchased or leased Electric Vehicle* Name of Dealership or Seller of Electric Vehicle Dealership or Seller Address Information* 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 Did you purchase a Level 2 Charger?*Yes, I bought one with this/for this vehicleNo, I already have one installedNo, I plan to charge via a regular house outletNo, I plan to charge at work or public Level 2 chargersOtherPlease upload copy of the New Hampshire Registration Certificate*Max. file size: 1 GB.Please upload copy of final sales contract or lease agreement*Max. file size: 1 GB.Section BreakHow did you hear about our EV Rebate program?*Advertisement in bill insertCar dealershipContractorEmailInternet search (yahoo, google, bing)Event (car show, tradeshow)Friend/ColleagueNHEC newsletterNHEC representativeNewspaperPostal MailSocial Media post (Facebook, Twitter,Linkedin)OtherSection C: SignaturesI have read and understood all materials, including the Terms and Conditions* Yes Download Eligible Equipment & Incentives, and read Terms and ConditionsMember Signature* Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ