Charge Up! - Portal

VOUCHER APPLICATION

Please fill out this form completely. All fields are required unless otherwise indicated.

Program Application Requirements

Please complete a separate application for each site location as distinguished by an address or intersection. Applicants may apply for more than one charger at a site, and may apply for multiple sites. However, a separate application must be submitted for each site.

BEFORE YOU BEGIN:

IMPORTANT: Please do not purchase or install any chargers until you have received an approved voucher for your project.
Be sure to review the program guidelines.
Have Electric Vehicle (EV) charger make & model information available. You'll need this to complete the application.
Have the required supporting documents ready for immediate upload (pdf or image files only). You won't be able to submit the application without the documents, and cannot save your progress on an unsubmitted application. Here's what you'll need:
- A completed IRS Form W-9
- Governing body resolution to execute the project application (Public Agencies only)
- Documented permission from the owner to install the chargers at the site (only if the applicant does not own the site)
- Supporting Documentation for additional funding for your project (if applicable)
- OPTIONAL: Other documentation (maps, etc) that may help to identify the intended location of the EV Chargers

Applicant Information

Applicant/Organization Name (per IRS Form W-9)

Organization Type (per Form W-9, item 3)

County where organization is located

Mailing Address

City

State

ZipCode

County

Physical Address and Mailing Address are the same

Physical Address

City

State

Zip Code

County

Primary Contact Person

Prefix

First Name

Last Name

Title (opt)

Primary Phone Number

Ext (opt)

Alternate Phone Number (opt)

Ext (opt)

Email Address

Contract Signin Authority

Prefix

First Name

Last Name

Title (opt)

Site Information

The project is located at the physical address

Site Address

City

State

Zip Code

County

Major cross streets where the charger(s) will be located

Corner where site is located at cross streets

For sites that will be publicly accessible, are any of the following points of interest located near by? (check all that apply)

Does the applicant/organization own the project site?

Yes

Is the site located near a highway?

Yes

Please provide a description of where the Electric Vehicle (EV) charger(s) will be located on the site (for example, location within the parking lot or structure).

Which of the following applies to your project at this site? Please select one.

The EV Charger(s) will be used solely by employees for workplace charging and will not be available for public access.

The EV Charger(s) will be used solely by the residents of a multi-unit dwelling and will not be available for public access.

The EV Charger(s) will be accessible for public EV charging 24 hours a day, 7 days a week.

The EV Charger(s) will be accessible for public EV charging at select times.

NOTE: Level 3 EV chargers must be available to the public 24 hours a day to be eligible for Charge Up! funding

Please complete the table to indicate when the charger(s) will be publicly accessible. Select N/A for both start and end times if the chargers will not be available on that weekday.

DAY	AVAILABLE FROM	AVAILABLE TO
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

EV Charger Information

Please list the chargers which you intend to install at the project site. Place each distinct charger model on a row of this table.
Click the "Add charger model" button to add additional models. All fields are required.

	MAKE	MODEL	LEVEL	PORT TYPE	QUANTITY

Add charger model

Disclosures

1. Have you or your organization previously participated in any of the Valley Air District's grant programs?

Yes

2. Have you applied for or received funding from another program or agency for the purchase and/or installation of the EV chargers you are including in this application?

Yes

Charge Up! is part of California Climate Investments, a statewide initiative that puts billions of Cap-and-Trade dollars to work reducing greenhouse gas emissions, strengthening the economy and improving public health and the environment — particularly in disadvantaged communities.

Before submitting, be sure to double check your email address. We'll send you a confirmation of receipt as well as a copy of your application.