Requestor's Full Name
*
First Name
Last Name
Requestor's Email
*
example@example.com
Requestor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Name
*
EV Charging Site Address (Non-residential Only)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Site Contact Name
*
First Name
Last Name
Site Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Point-of-Contact
*
First Name
Last Name
Chargers Manufacturer(s) [if Known]
Charger Model(s) [if Known]
Charger Serial Number(s) [if Known]
Scope of Work
Select All That Apply
*
Cable Swaps
Ev Charger Derating
Sim Card Swaps
Credit Card Readers
Onsite OEM Support for Technician
Other
Charger Swaps
Cable Length Needed
Brand of Cable Needed
Cable Configuration - NACS, CCS1, GPT, CHAdeMO
EV Charger Derating - Do you need your charger to be derated?
Yes
No
Sim Card Swaps - Will the sim cards be shipped by the OEM?
Yes
No
Credit Card Reader - Do you need a credit card reader installed?
Yes
No
Onsite OEM Support for Technician - Please provide supporting OEM documentation
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