Electric Vehicle Rebate Application

EV Rebate Application

Section A: MEMBER INFORMATION
Member Name (as it appears on NHEC bill)*
NHEC Account Number*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address*
Street Address Address Line 2 City State ZIP Code
Daytime Phone #*
Email*
Section B: Electric Vehicle Information
My Electric Vehicle was
Electric Vehicle Classification
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 State ZIP Code
Did you purchase a Level 2 Charger?*
Please 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 Break
How did you hear about our EV Rebate program?*
Section C: Signatures
I have read and understood all materials, including the Terms and Conditions*
- Yes
Download Eligible Equipment & Incentives, and read Terms and Conditions
Member Signature*
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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Section A: MEMBER INFORMATION