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2. Please fill out the information below:
4. Name on Account*
5. Service Account Number
7. Anaheim Service Address*
9. Contact Phone Number
10. Email Address*
12. Do you currently own an electric vehicle?

    1. Yes

    1. No
13. Are you planning to purchase or lease an electric vehicle in the near future?

    1. Yes

    1. No
15. What is the year, make and model of the electric vehicle?
17. What can we help you with?

    1. Charger
    2. Meter Spot
    3. Permits
    4. Rebate
    5. Rates
    6. Other
19. Comments / Questions
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21. 1. Receive an email copy of this form.
22. Email address

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23. Submit

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