Application form for public charging stations

You want to request a charging station for:(Required)

Near my home location

Elsewhere

First name(Required)

Surname(Required)

Email address(Required)

Phone number(Required)

Street name(Required)

House number(Required)

Postal code(Required)

City(Required)

Municipality(Required)

Street name(Required)

House number(Required)

Postal code(Required)

City of(Required)

Would you also like to request a charging station near your work?(Required)

Yes (we will contact you for more information)

Do you have an electric car?(Required)

Yes, I have an electric car

No, I'm getting an electric car soon

What is the make and type of car for which you are requesting the charging station?