Applicant Name *

First

Last

EnergyUnited Account Number *

Address *

Street Address

Address Line 2

City

State

Zip/Postal/Code

Country

Phone

Is the vehicle registered in this name? *

Yes

No

If not, name on title *

First

Last

Vehicle Information:

Make *

Model *

Year *

Vin #

County vehicle is registered in *

Expected average daily driving distance (in miles) *

I plan to keep this vehicle *

1 year

2 years

3 years

More than 3 years

Charging Station Information:

Brand name *

Model # *

Serial # *

Time of day I expect to charge the vehicle (Example: 6 - 10 pm) *

Installation Contractor Name *

Address *

Street Address

Address Line 2

City

State / Province / Region

Zip/Postal/Code

Country

Phone *

Electrical permit/inspection # *

Total installation costs *

Copy of County Inspection must be attached for processing rebate *

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Copy of Sales Invoice must be attached for processing rebate *

Upload your File Here