OLD - Residential Electric Vehicle Rebate Form

1. Customer Information

Name *This question is required.

Account Number This question requires a valid number format.

Address *This question is required.

City *This question is required.

State *This question is required.

Zip Code *This question is required. This question requires a valid number format.

Email Address

Phone Number *This question is required.

Is mailing address different from the address above?

Mailing Address *This question is required.

Mailing City *This question is required.

Mailing State *This question is required.

Mailing Zip Code *This question is required. This question requires a valid number format.

2. Do you currently own an Electric Vehicle? *This question is required.

3. Information provided here helps us better understand the EV owners we serve and improve our programs.

Vehicle Make *This question is required.

Vehicle Model *This question is required.

Vehicle Year *This question is required. This question requires a valid number format.

Battery Size

If purchased at dealership; what city?

Dealership Name