Residential Off-Peak EV Charging Station Application

Section A: MEMBER INFORMATION
Member Name*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Member Account Number*
Meter Number:*
How did you hear about this program?
Please tell us how you first heard about the charger incentive program.
Section B: INSTALLATION INFORMATION
Physical Address ( where EV Charger will be installed)*
Street Address Address Line 2 City State ZIP Code
Please provide the make/model of Level 2 Charger
Proposed Project Completion Date
MM slash DD slash YYYY
Section D: Signature
Terms and Conditions*
- Yes
I have read and understood all materials, including the Terms and Conditions
Phone
This field is for validation purposes and should be left unchanged.

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Section A: MEMBER INFORMATION