Part 1: Site Information

Reseller NameJacomb LightingINF AssociatesDVM IndustriesBasin PowerEn Power GroupECS Global ServicesRPACECMEarthlight TechAccord PowerVBS EnergyInfinity Energy

Customer Name

Site Name

Site Address

City

StateN/AAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Postal Code

Site Administrator Name

Site Administrator Contact Info

Part 2: Equipment and Order Information

Communications

Cell

Wifi

Ethernet

Upload Purchase Order

EVSE ManufacturerABBBTCPowerEV BoxPhihongPowerChargeTritiumWallbox

EVSE ModelTerraACTerra54

Total # of ports

Term of plan

1 year3 years5 years

Expected Completion date

Part 3: Location Information

Total # of Sublocations

Submit