LinkedInThis field is for validation purposes and should be left unchanged.Name(Required) First Last Installation Service Address(Required)Address where you receive electric service and where the vehicle is registered and/or level 2 charger will be installed. Street Address Address Line 2 City ZIP Code Mailing Address(Required) Same as installation address Street Address Address Line 2 City State 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 ZIP Code Phone(Required)Email(Required) Which rebate are you applying for?(Required) Vehicle Registration 240 Volt Outlet Level 2 Charger A CEC engineer has reviewed my level 2 charger installation?(Required)Prior to the installation of any new equipment, a CEC engineer must review the existing system infrastructure to ensure it is properly sized to accommodate your new equipment. If you select no, please complete and submit the form. After a CEC Engineer has reviewed the information, we will contact you with further instructions. If you select yes, please complete and submit the form including the required uploads. Yes No A CEC engineer has reviewed my 240 Volt outlet installation?(Required)Prior to the installation of any new equipment, a CEC engineer must review the existing system infrastructure to ensure it is properly sized to accommodate your new equipment. If you select no, please complete and submit the form. After a CEC Engineer has reviewed the information, we will contact you with further instructions. If you select yes, please complete and submit the form including the required uploads. Yes No Has the level 2 charger been installed?(Required)If your system has not been reviewed by a CEC engineer, but is already installed, please complete the additional sections of the form including the uploads. After a CEC Engineer has reviewed the information, we will contact you with further if necessary. Yes No Has the 240 Volt outlet been installed?(Required)If your system has not been reviewed by a CEC engineer, but is already installed, please complete the additional sections of the form including the uploads. After a CEC Engineer has reviewed the information, we will contact you with further if necessary. Yes No Brand of Electric Vehicle(Required)Model of Electric Vehicle(Required)Brand of Charger Installed(Required)Model of Charger Installed(Required)Where was the level 2 charger purchased?(Required)-Select one-InstallerRetailerOnlineOtherWho installed the charger or outlet?(Required)Total installed cost of EV charger or outlet before rebates(Required)Please enter a number from 0 to 10000.DMV Registration Upload(Required)Please upload a copy of your DMV registration for the electric vehicle registered at your service location. Drop files here or Select files Max. file size: 100 MB. Receipt Upload(Required)Please upload a copy of your receipt or invoice showing the brand, model number, purchase date and price of the qualifying level 2 charger and/or 240 Volt plug. Drop files here or Select files Max. file size: 100 MB. Equipment Photo Upload(Required)Please include a photo of the installed charger along with a photo of the model and serial numbers. Drop files here or Select files Max. file size: 100 MB. Installation ChecklistFollow the manufacturer's installation instructions exactly. Failure to do so will result in disqualification from the program, may void the manufacturer's warranty and may result in lower than expected system performance.I certify that the following installation items are complete and accurate:(Required) System is installed to manufacturers specifications Installation complies with National Electric Code along with local, county and state requirements Charger or outlet is new, not resold, rebuilt or received from warranty insurance claims or won as a prize Electronic Member SignatureRebate amounts and program requirements are subject to change or be discontinued at any time by Central Electric Cooperative (CEC). CEC disclaims any warranty, whether expressed or implied, regarding the equipment listed above and for materials or labor associated with installation, maintenance, repair, or any energy savings associated with use. All locations and jobs are subject to inspection. Electricity usage, job information and all application data may be analyzed or shared to partnering third parties by participating in electric vehicle programs by CEC. Equipment and installation of the job must meet all program criteria to qualify for rebates. Rebates $250 and under will be credited to a member’s bill.Consent(Required)By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature. I understand that I can be held liable if I provide false or misleading information. I certify the above information is true and correct and I am the person submitting the form(Required)Type Full NameConsent(Required) I agree to the CEC Privacy Policy.
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