Residential Off-Peak EV Charging Station Application Residential EV Charging Station Program Application Section A: MEMBER INFORMATIONMember Name* First Last 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 Phone*Email* Member Account Number* Meter Number:* How 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: INSTALLATION INFORMATIONPhysical Address ( where EV Charger will be installed)* 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 Please provide the make/model of Level 2 Charger Proposed Project Completion Date MM slash DD slash YYYY Section D: SignatureTerms and Conditions* Yes I have read and understood all materials, including the Terms and ConditionsNameThis field is for validation purposes and should be left unchanged. Δ