Residential Off-Peak EV Charging Station Application Residential EV Charging Station Program Application Section A: MEMBER INFORMATIONMember Name * Required First Last Mailing Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required Member Account Number * RequiredMeter Number: * RequiredHow 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) * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Proposed Project Completion Date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Section D: SignatureTerms and Conditions * Required Yes I have read and understood all materials, including the Terms and ConditionsCommentsThis field is for validation purposes and should be left unchanged.