Employee EV Stabilization Form

Employee EV Stabilization Form

Employee Name:    Employee ID:

Personal Information

Position Information

Proposed Start Date for EV Program:    Salary (annually): $

Vehicle Details

Year:    License Plate:    VIN:

CCS   CHAdeMO   Type 2   Tesla (adapter)

Charging Location and Schedule

Charging Equipment & Installation

I will use employer-provided charging equipment:    I will use my personal/portable charger:

I request employer installation of dedicated EV charging infrastructure:

Estimated employee contribution (if any): $    I authorize payroll deduction:

Safety, Compliance & Data Consent

By enrolling I acknowledge and agree to comply with all site safety rules for EV charging and parking, and will not alter or tamper with charging equipment. I will immediately report any equipment damage, electrical hazard, or incident to Facilities.

I consent to collection and retention of charging session data (including times, energy consumption, and connector status) for purposes of billing, load management, and program administration:

I agree to follow additional operational requirements that may be established to protect electrical systems and ensure equitable access. Failure to comply may result in suspension of charging privileges.

Liability, Indemnification & Revocation

The employee assumes responsibility for loss, theft, or damage to personal charging equipment and for any damage caused by improper installation or use. The employee hereby indemnifies and holds the employer harmless from claims arising from the employee's negligent use of charging equipment, except to the extent caused by the employer's gross negligence or willful misconduct.

The employer reserves the right to suspend or terminate an employee's participation in the EV Stabilization Program for safety, capacity constraints, or policy violations. Upon separation of employment or program termination, the employee is responsible for removal of personal equipment and restoration of the site unless other arrangements are made in writing.

Employee acknowledges and accepts liability, indemnification, and revocation terms

Legal Disclosures

AT-WILL EMPLOYMENT: Nothing in the EV Stabilization Program enrollment alters the at-will employment relationship between the employee and the employer unless expressly stated in a separate written agreement signed by authorized representatives.

EQUAL OPPORTUNITY: Participation in the EV Stabilization Program will be administered in a nondiscriminatory manner consistent with applicable equal employment opportunity policies and laws.

Employment History (most recent first)

Title:    From:    To:

Title:    From:    To:

Education

Professional References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Applicant Certification & Authorizations

I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that falsification of information may result in denial of enrollment or disciplinary action. I authorize the employer to verify any information provided herein and to contact the references and prior employers listed above for the purpose of evaluating this request.

I authorize any necessary electrical work at the identified site and acknowledge that certain costs may be allocated between the employer and employee as agreed in writing. I further authorize the employer to charge for electricity usage or to collect charges by payroll deduction where prior written authorization is provided.

I authorize investigation of all statements contained in this form and consent to a background check and verification of prior employment as necessary for program enrollment:

I certify under penalty of law that the foregoing is true and correct, and I acknowledge that submission of this form constitutes a request to participate in the employer's EV Stabilization Program and acceptance of the terms set forth above.

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