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Eugene Water & Electric Board <br /> 2016 Electric Vehicle Commercial Rebate Application <br /> Please read and agree to comply with all terms and conditions of this Application and any <br /> corresponding forms. Incomplete paperwork will be sent back to the customer for completion. <br /> SECTION 1— <br /> CUSTOMER INFORMATION <br /> City of Eugene Public Works 1820 Roosevelt Blvd Eugene, OR 97402 victoria.m.doyle@ci.eugene.or.us <br /> Business Name Address Email Address(for EWEB use only) <br /> Victoria M Doyle,Program Coordinator Fleet and Radio Communications 541-682-4863 <br /> Name of Authorized Contact Person Title of Authorized Contact Person Phone# <br /> Mailing Address (If different than above) City State ZIp <br /> SECTION 2 PAYMENT INFORMATION <br /> t *NOTE: Payment must be made to EWEB's customer associated with the above facility. <br /> Make check payable to: City of Eugene,ATTN: Fleet Services please credit:EWEB Acct 241536-180 <br /> 1820 Roosevelt Blvd Eugene, OR 97402 Contact Name Phone Number <br /> Payee Mailing Address City State Zip <br /> Tax Status: 0 individual/Sole Proprietor El C Corporation ❑S Corporation 0 Partnership 0 Trust/Estate 0 LLC <br /> 51 Exempt Payee 0 Other <br /> Tax ID Number: El E ®El Q 0©® I$ Employer identification Number 0 Social Security Number <br /> SECTION 3 REBATE PRODUCT INFORMATION <br /> Please enter the vehicle make,model,model number,year,VIN#,number of units,rebate per unit,and rebate total in the applicable table(s)below.Please <br /> read the Program Information carefully before proceeding with your purchase. <br /> REBATE INFORMATION <br /> Vehicle Make Model Year VIN# Rebate Amount <br /> ($200/EV) <br /> N 55/t tJ • l-.2 A F 2.0 Ili, V N 4 B7_23 3 c-PK G c NS5 Z'1 $ l v u — <br /> $ <br /> $ <br /> TOTAL REBATE AMOUNT: $ <br /> SECTION 4 PLEASE ANSWER THE FOLLOWING QUESTIONS (CHECK ONE): <br /> Did you purchase this vehicle as part of the rEV Up Eugene Nissan LEAF discount program? ❑ YES )(NO <br /> How do you plan to charge your vehicle most of the time? PLACE OF BUSINESS❑ EMPLOYEE RESIDENCE <br /> If you plan to charge at home,will you install a 220 Volt Level 2 residential charging station? ❑ YES `c4 NO ❑ ALREADY HAVE ONE <br /> What is your estimated average daily mileage? o <10 ❑ 11-25 X26-40 ❑ 40+ <br /> Can EWEB add you to a contact list for other information related to electric transportation ❑ YES y NO <br /> and similar programs? <br /> REV:10/2016 1 <br />