Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code REMC Account Number(Required) Phone Number(Required)Email Address(Required) EV Make(Required) EV Model(Required) Purchase Date (mm/dd/yyyy)(Required) Month Day Year When do you charge your EV?(Required) Do you have a home charger for your vehicle?(Required) Yes No Is your EV total electric or hybrid?(Required) Total electric Hybrid Are you interested in receiving a free charger through the Cooperative Charge Program?(Required) Yes No Do you agree to let REMC periodically access usage data to dtermine impacts of EV charging on our distribution system? (Including charging times, charging demand, and charging duration)(Required) Yes No NameThis field is for validation purposes and should be left unchanged.
