Fleet & Parking Services
1100 Airport Rd SE
Salem, OR 97301-6082
Employee Electric Vehicle Charging Application
503-378-5090
503-378-2157 fax
state.parking@oregon.gov
Employee Name
Employee ID#
Last
First
MI
Agency Name
Agency Number
Division/Section
Worksite Address
Street/City/Zip
Work Phone
Email
For events & issues related to your assignment
YOUR VEHICLE DESCRIPTION:
Vehicle Year/Make/Model
State
Plate
Vehicle Battery Capacity______________________________________________ (required)
Charging Site (charging address) ___________________________________________________________________
Agency PCA# ______________ (designate building/section where monthly charge accounted to; if blank = 81900)
For DAS-owned buildings not controlled by State Parking, requests to access EV infrastructure will be evaluated and
approved through the DAS Safety Manager and DAS Operations & Maintenance. For non-DAS buildings and sites,
approval from your agency is required to access the EV Charging infrastructure. This approval must come from your
agency’s Safety or Risk Manager. Approved by
:
Title: __________________________________
Signature: _________________________ Date: _______________
Employees must pay a minimum monthly charge to access state-owned EV charging. Oregon Laws, Chapter 526, requires the
state to recover the costs to provide EV charging. For full charging of vehicles with a battery capacity of greater than 10kWh,
the minimum rate is $20 per month. For full charging of vehicles with a battery capacity of less than 10kWh or half-day, Level 1
only charging of vehicles with larger battery capacities, the minimum charge is $10 per month.
The rate per month may be higher at some sites depending on cost to install and maintain the infrastructure provided. The rate
per month will not be prorated due to employee absence, vacation, and early termination of this agreement, or for any other
reason within a calendar month. Please refer to
Statewide Fleet Management policy
107-009-040, Section XIV.
I hereby request:
☐ Full day Level 1 or Level 2 charging for a vehicle with a battery capacity of 10kWh or less; $10 per month.
Or
☐ ½ day Level 1 or Level 2 charging for a vehicle with a capacity of more than 10kWh; $10 per month. By requesting ½ day
charging I agree that I will ensure my vehicle is only consuming a maximum of 10kWh of electricity per day. Failure to comply
with this limit may result in revocation of all current and future EV charging privileges and parking assignments with DAS
Parking Services.
Or
☐ Full day Level 1 or Level 2 charging for a vehicle with a battery capacity greater than 10kWh; $20 per month.
U:\PKG\Forms\EVChargingApp.docx
Updated 8/29/2017 ICD
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