CommentsThis field is for validation purposes and should be left unchanged.Legal Name & Address of Interconnecting PartyCompany NameContact Person(Required)Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone (Daytime)(Required)Telephone (Evening)(Required)FaxEmail(Required) Ownership(Required)Include % ownership by any electric utility.Facility InformationLocation Address (if different than above)(Required) Same as previous Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Inverter Manufacturer(Required)Model(Required)Nameplate Rating:(kW)(Required)(kVa)(Required)(AC Volts)(Required)Single or Three-Phase(Required) Single Three-Phase System Design Capacity: (kW)(Required)(kVa)(Required)Prime Mover:(Required) Photovoltaic Reciprocating Engine Fuel Cell Turbine Other Energy Source:(Required) Solar Wind Hydro Diesel Natural Gas Fuel Oil Other UL1741 Listed?(Required) Yes No Need an air quality permit?(Required) Yes No Not sure Have you applied for the permit? Yes No Estimated Install Date (MM/DD/YYYY)(Required) Month Day Year Estimated In-Service Date (MM/DD/YYYY)(Required) Month Day Year Customer Signature (attach manufacturer’s cutsheet showing UL1741 listing and sign below)(Required)I hereby certify that, to the best of my knowledge, all of the information provided in this application is true. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Signature (Full Name & Title)(Required)FileMax. file size: 100 MB.
