Date: *

MM

DD

YYYY

Name: *

First Name

Last Name

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone: *

(###)

###

####

Which BENCO rate do you want to have your electric vehicle on? *

Storage Rate

Time-of-Use Rate

Attach to an existing dual-fuel meter

Electrician Phone: *

(###)

###

####

Meter Type: *

Subtractive Metered Service

Parallel / Separate Service

Unknown

Is the meter ready to be set? *

Yes

No

Acknowledgement Agreement *

By checking this box I acknowledge that I have read and understand the terms and conditions of the Electric Vehicle program at BENCO Electric Cooperative.

Yes