Name(Required) First Last Account Number(Required)Email(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code BMV Registration Photo Upload – $50 Incentive for BEV Owners. Feel free to omit the VIN number.(Required) Drop files here or Select files Max. file size: 500 MB. Type of Vehicle(Required) BEV (Battery Electric Vehicle) PHEV (Plug-in Hybrid Electric Vehicle) Voltage of Primary Charger at your Residence(Required) Level 1 (120 volts) Level 2 (240 volts) Time-of-Use (TOU) Rate Option – $75 Incentive for BEV and PHEV Owners(Required) I authorize BCREMC to change my rate to TOU, for a minimum of 12 months. I’m already enrolled in the TOU rate. I'm a BEV owner but do not wish to sign up for the TOU rate. Terms and Conditions(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Electronic Signature (Full Name)(Required)
