EV Charging Station Registration

1

Titleholder/Resident* This field is required.

First Name

Last Name

2

Kentlands Street Address* This field is required.

3

Email* This field is required.

example@example.com

4

Cell Phone* This field is required.

Please enter a valid phone number.

5

Phone (other)

Please enter a valid phone number.

6

Electric Vehicle Information:
Vehicle Make Example: Chevy *
Model Example: Volt *
Year *
Color *
Tag Number *
Tag State *

7

Additional Electric Vehicle Information:
Vehicle Make Example: Chevy
Model Example: Volt
Year
Color
Tag Number
Tag State