SOLECTRIC AGENT APPLICATION FORM

Become a SOLECTRIC Accredited Agent

* Indicates required field

Choose Your Agent Option *

Name of Company Representative *

First

Last

Name of Referred Agent if any *

Identification Numbebr *

Agent Fees - Select One *

Email *

Proposed Starting Month *

Phone Number *

Number of ASSOCIATES *

Physical Address (This Information is important for SOLECTRIC IESS Installation)

Physical Address *

Community *

City / Province *

Building Owner *

Type of Property *

Number of Occupants *

If Applicant is a Company (for an individual, complete the first section only)

Name of Director One *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How many Shares do you own *

Name of Director Two *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How many Shares do you own *

Name of Director Three *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How many Shares do you own *

Other information you may want to share *

Submit

SOLECTRIC Agents for Development

Become a SOLECTRIC Accredited Agent

Physical Address (This Information is important for SOLECTRIC IESS Installation)

If Applicant is a Company (for an individual, complete the first section only)

SIMPLE CHARGING SYSTEM