Electric Vehicle Charging Incentive Application

Section A: MEMBER INFORMATION
Business Name (as it appears on NHEC bill)*
Contact Person*
First Last
Title*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Member Account Number*
Meter Number:*
How many hours per week is your business open to the public?
Additional Information
How did you hear about this program?
Please tell us how you first heard about the charger incentive program.
Section B: INSTALLER INFORMATION
Installer's Name*
Contact Person*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Section C: INSTALLATION DETAILS
Please upload site diagram where EV charger will be installed*
Max. file size: 16 MB.
Project Address ( where EV will be installed)*
Street Address Address Line 2 City State ZIP Code
How Many Chargers Will be Installed?*
Proposed Project Start Date*
MM slash DD slash YYYY
Circuit Voltage serving charger*
Circuit breaker poles (2/P, 3/P)*
Please upload any installation documentation.
Max. file size: 16 MB.
Section D: Signature
Terms and Conditions*
- Yes
I have read and understood all materials, including Terms and Conditions
Name
This field is for validation purposes and should be left unchanged.

Section A: MEMBER INFORMATION