Employee Electric Vehicle Charging Application - Oregon Department Of Administrative Services Page 2
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1
2Fleet & 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
EV CHARGING GUIDELINES AND INFORMATION
Employee Name
Employee ID#
Last
First
MI
ACCEPTANCE OF AN EV CHARGING ASSIGNMENT INCLUDES A SIGNED AGREEMENT TO ADHERE TO THE
GENERAL RULES RELATING TO ALL EV CHARGING AS FOLLOWS:
•
Assignment of EV charging privileges will be on a first come, first served basis.
•
Employees may charge their vehicles only at electrical outlets and EV chargers designated for their use by their
agency.
•
Extension cords may be used only by permission of the agency safety manager and must be of a sufficient gauge
and quality compatible with EV charging.
•
If extension cord use is approved, for any places the cord crosses pedestrian traffic areas, the employee must
provide and use a high visibility cord cover to prevent cord damage and trip hazards.
•
Employee cords may be inspected by the agency periodically and if found to be damaged or worn, the use of state
charging infrastructure may be revoked until the cord is replaced or properly repaired.
•
When assigned use of a Level 2 charger, employees may be required to share the charger and move their vehicle
after their vehicle has reached full charge or after a specified length of time for other employees to use the same
charger. Sharing a charger does not reduce the rate per month an employee pays.
I understand that EV charging is regulated by the Department of Administrative Services and is subject to the provisions of
Oregon Laws, Chapter 526,
Statewide Fleet Management Policy
107-0009-040, and the general rules listed below or on the
reverse of this form. In addition, my agency may have additional conditions or policies related to EV charging. By accepting an
EV charging assignment made by the Department, I agree to abide by these laws, policies, rules, and conditions. I further
understand that failure to abide by these rules and laws may result in citation, prosecution and/or loss of charging privileges.
Post-tax Payroll Deduction Authorization
I hereby authorize DAS to deduct from my salary or wages due me by virtue of my employment with the State of Oregon, all
sums owed to the State of Oregon for use of the EV charging infrastructure I have been authorized to utilize. I understand that
the charge may increase or decrease. Payroll deductions for EV charging are made in arrears and are post-tax. This request
and authorization shall remain in force until canceled by me in writing or by email to the Department of Administrative
Services, State Parking: state.parking@oregon.gov.
Employee Signature
Date
OFFICE USE ONLY
$20 Monthly Rate____________Ded. Code: PKXN 109 Or
$10 Monthly Rate____________Ded. Code: PKXN 108
Effective Date____________________________ Payroll Notification_______________________
U:\PKG\Forms\EVChargingApp.docx
Updated 8/29/2017 ICD
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