Residential Off-Peak EV Charging Station Application

Section A: MEMBER INFORMATION
Member Name * Required
First Last
Mailing Address * Required
Street Address Address Line 2 City State ZIP Code
Phone * Required
Email * Required
Member Account Number * Required
Meter Number: * Required
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) * Required
Street Address Address Line 2 City State ZIP Code
Proposed Project Completion Date - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Section D: Signature
Terms and Conditions * Required
- Yes
I have read and understood all materials, including the Terms and ConditionsTerms and Conditions
Member Signature * Required
Date - must be mm/dd/yyyy format * Required
Date Format: 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