Home Charger Rebate Application Member InformationHome Charger InformationAgreementHome Charger Rebate Application NOTICE: Please note, this application must be completed within 45 days of purchase of the Level 2 home charging station. Charger must be purchased on or after October 1, 2020. Must be NRTL/UL listed and cannot be a portable charger. Name * First Last * Last Charger Installation Address Charger Address * Charger Address Address Address Address 2 Address 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Mailing Address (if different from installation address) Mailing Address Mailing Address Address Address Address 2 Address 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Member Number * Phone Number * Email Address * Photo ID * Drop photo ID here or click to upload Choose File Maximum file size: 10MB Please upload a photo of your driver's license. Upload requirements: One file only, 10mb limit. Allowed types, jpg, jpeg, png, pdf. If you are human, leave this field blank. Next
