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Member name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email address*

Phone number*

Holy Cross Energy Account Number*

If you need help with your account number please call our MSR department at 970.945-5491.

Which brand of charger do you plan on purchasing?

EnelX Flo (X5 Model Only) Emporia ChargePoint

Car make

Tesla, Chevy, Nissan, GM

Car model

Model X, Bolt, Leaf

Vehicle Identification Number (VIN)

Annual miles

Expected Annual Mileage

How do you want to pay for your electrical work?*

I will pay my electrical contractor directly. HCE will pay my electrical contractor and I will pay the cost back over 3 years on my electric bill (EVSE Service Agreement).

Do you have a different mailing address?*

Yes No

Mailing address*

Address Line 1

Address Line 2

City

State

ZIP Code

Approval

This is

Approved Rejected

Approval Code*

Reason for rejection

Not Holy Cross consumer for a minimum of 12 consecutive months Member has have been delinquent on any of the consumer’s bills in the last consecutive 12 months. Member has more than two late payments in the last consecutive 12 months.

This will be included in the email.