Electric Vehicle Charger Rebate Form
Please fill in all required fields. If you have an questions, please give us a call at 770-385-2875 or contact us on www.ssemc.com
Contact Information
First Name:
*
Last Name:
*
Account Number:
*
Service Address:
*
City:
*
Zip:
*
Email Address
*
Phone Number:
*
Rebate Information
Electric Vehicle Year:
*
Purchased within last 90 days?
*
Yes
No
Yes
No
Date Charger Was Purchased:
*
Date of Installation:
*
Is it a Level 2 Charger and UL Rated?
*
Yes
No
Yes
No
Photo of Receipt:
*
Drop files here, or
browse to attach files
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Confirmation Required
Are you sure you want to remove the selected file?
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Photo of Installation
*
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browse to attach files
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Confirmation Required
Are you sure you want to remove the selected file?
Confirm
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Photo of Charger Serial #:
*
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