Public Site Type Application Level 2 Chargers & DC Fast Chargers Eligible Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Site name *Provide site name, Ex. Winthrop Red Apple.Partner / Name of Site Proposer: *Property manager/municipality/tribeLocation *Address Line 1Address Line 2CityInstallation StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLegal Owner Contact Name, phone, email for legal owner Name (copy) *FirstLastPhone *Email *Legal Owner Support? *Has the legal owner agreed to the charger installation and willing to attest to supporting this project? Yes/NoYesNoSite Contact Person Name, phone, email of person managing the installation (lead applicant) Name *FirstLastPhone (copy) *Email (copy) *Operational HoursNote operational hours and any other restrictionsNumber of L2 PortsTotal number of ports that applicant is seeking funding for (Maximum allowable ports (20)201918171615141312111098765432L2 Port Connector TypeAll sites must have either J1772 or NACSJ1772NACSBothNumber of DCFC PortsTotal number of ports that applicant is seeking funding for (Maximum allowable ports (6)654321DCFC Port Connector TypeAll sites must have either CCS or NACSCCSNACSBothTotal # of DCFC Chargers at siteTotal number of DCFC chargers at site. # of parking spaces at siteNumber of total parking spaces at site# of L2 EV Parking spaces at siteNumber of L2 EV parking spaces to be installed# of DCFC EV Parking spaces at siteNumber of DCFC EV parking spaces to be installedCommitment Apprenticeship Labor *YesNoNot DeterminedProject Labor Agreement *YesNoNot DeterminedFuture-Proofing Adder – Number of stubs outs Per EV Ready Parking Spot:Number of stub-outs for Level 2Future-Proofing Adder – DCFC Per EV Ready Parking SpotNumber of stub-outs for DCFCSubmit