Plug-in NC Member Application

Name*

First Last

Email*

Phone*

Organization Applying*

Address*

Street Address Address Line 2 City State ZIP Code

North Carolina County*

Website

Charging Station Information

How many charging stations have you installed?

What make / model are they?

What is the rated input voltage and input current of your stations?

Electric Fleet Vehicle Information

How many electric vehicles are part of your fleet?

What make / model are they?

Education and Outreach Information

If your organization participates in electric vehicle education and outreach, please describe your efforts.

Additional Information

Please provide a quote for your Plug-in NC profile. Include information on why you decided to support electric vehicles and the benefits you have seen from your efforts.*

Please provide at least one picture of your charging station or electric fleet vehicle, or your company logo.*

Max. file size: 50 MB.

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