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2. 
3. Official Use Only

   Incentive:                  EV:                          Date:

5. Electric Vehicle Level 2 Charging Station Installation Incentive
7. Customer Name*
8. Account #*
10. Email Address*
12. Installation Address*
14. City/Zip Code*

    (Charging station must be installed in our service territory)

16. Mailing Address

    (if different than installation address)

18. City/State/Zip Code
20. Brand of Charger *
21. Model Installed
23. Make and model of electric vehicle (EV) being charged (as of date of submission):
25. Make*
26. Model*
28. Incentive Amount: $500 (limited to one incentive per location).
30. Check

    1. Will be mailed to the address above
31. Installation

    1. Must be in compliance with applicable local, county, and state code requirements
32. Installation Date:*
    Installation Date:
34. Upon signing this agreement, customer acknowledges the following

36. Incentive offer(s) may be changed or discontinued at any time by FGL&P.  FGL&P disclaims any warranty, whether expressed or implied, for any materials or labor associated with installation, maintenance, or repair.  FGL&P reserves the right to inspect installed product(s).  Limited to one rebate per location.  Please allow 3-4 weeks for processing.  Charger must be 220V or higher.  

    I understand the above and certify that I am a customer of FGL&P, that the Level 2 charger is installed.

38. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature*
41. Date*
    Date

43. Submit completed form and upload purchase receipt.

44. Purchase receipt*

    (Including purchase date)

46. EV LEVEL 2 CHARGING STATION REBATE FAQ'S

    Q: How do I decide which Level 2 charger to buy?

    A: We recommend reviewing your EV’s owner’s manual to see which chargers are recommended for your

    model of EV. Also, it’s important to consult with your electrician to discuss the charger you’ve selected

    prior to making that purchase.

    Q: I’d like to install a Level 2 charging station at my business. Do businesses qualify for this

    program?

    A: Yes. The incentive is limited to one per location. Business, industrial, and residential customers all qualify

    for this incentive, and it may be used to help with the cost of installing a Level 2 charger.

    Q: Is this incentive retroactive?

    A: Yes.  This incentive is retroactive, and we will work with you if you can't find you receipt.

48. Questions

    Contact Eddie Littlefield at elittlefield@forestgrove-or.gov or call 503-992-3296

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

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