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First Name *

Last Name *

Phone Number *

Email Address *

City *

Year House Built (approximate) *

Garage Type *

• Attached
• Detached

Circuit Breaker Panel Location *

• Garage
• Basement
• Interior House Room
• Other

Brand (approximate) You

Basement Ceiling Type (If Garage attached and Panel is in Basement)

• Plaster / Drywall Ceiling
• Suspended / Drop Panel Ceiling
• Unfinished Ceiling

Distance from Garage to Circuit Breaker Panel (Feet or Meters) (approximate)

Car Make / Model

Number of Miles Driven Daily (approximate)

Have You Purchased a Charger? *

• Yes
• No

Charger BrandTeslaCharge PointWall BoxJuice BoxGMBMWNEMA 14-50 CordOther

Notes / Comments

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