Testpagina Gravity Forms

Charging Services Order Form (test Suana)

"*" indicates required fields

Charging Services Order Form (test Suana)

Step 1 of 1

100%

Use of the charging station

How would you like to use your charging station?*

I only want to use my charging station for private purposes, but I would like to receive an overview of the charging sessions.

I would like to use my charging station to charge my company car and obtain reimbursement of the costs from my company or employer.

I want to make my charging station available to third parties and be reimbursed for the electricity supplied. I also would like the option of receiving a direct reimbursement from my employer for the home charging sessions of my company car.

Charging station for private use – Charging station details

Charging station brand*

Charging station(s) serial number(s)*

In case you specify multiple charging stations, please write the serial numbers below each other. The serial number can be found on the charging station itself, usually on a sticker. If you cannot find the serial number immediately, please contact your installer, who can help you. A serial number should be a unique number of at least 5 characters.

Charging station location: Street name*

Charging station location: House number*

Charging station location: Postal code*

Charging station location: City / village*

Charging station location: Country*

Where is the charging station installed?*

Against the building

Separate from the building, e.g. in a car park or parking area

Name of the installation company*

Charging station for private use – Energy contract

Here we want to know who needs to be reimbursed for the charging sessions from the charging station.

Who pays the electricity bill of the house/building to which the charger is connected?*

The electricity bill is paid for by me as an individual.

The electricity bill is paid for by my company.

Charging station for private use – Personal information

If your address is the same as the charging station itself, you do not need to fill in the address fields.

The address of the charging station location is the same as the address below*

Yes – The address fields are the same. I will leave the address fields below blank.

No – The address fields are different. I will fill in the address fields below.

Surname*

First name*

Phone number*

Personal email address*

This email address will serve as your login.

Street name

House number

Postal code

City / village

Country

Private contract

I want to order a Private contract for € 3.75 / month excluding VAT (for each connector):*

Yes

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy.

Terms of services
Privacy policy

Charging station for private use – Company details

Company name*

Type of company

(e.g. private limited company, public limited company, sole proprietorship etc.)

VAT number*

Surname of the company contact person*

First name of company contact person*

Company street name*

Company house number*

Company postal code*

Company city / village*

Company country*

Company phone number*

(you only need to fill in this field if the email address is different from the one you have already entered)

Company billing email address

(not mandatory, only if different from the login e-mail address)

Private contract

I want to order a Private contract for € 3.75 / month excluding VAT (for each connector):*

Yes

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy

Terms of services
Privacy policy

Charging card – private contract

Do you already have a charging card(s)?*

Yes

Charging station for professional use – Manager or employee

Choose one of the options below:*

I am the manager and my company does not have a Mobiflow account yet.

I am an employee.

Charging station for professional use – Charging station details

Charging station brand*

Charging station serial number*

(Remark: the serial number can be found on the charging station itself, usually on a sticker. If you cannot find the serial number immediately, please contact your installer, who can help you. A serial number should be a unique number of at least 5 characters.)

Charging station location: Street name*

Charging station location: House number*

Charging station location: Postal code*

Charging station location: City / village*

Name of the installation company*

Charging station for professional use – Personal & company information

If this address information corresponds to the address details of the charging station that you have just filled in, you do not need to fill them in again, with the exception of the fields ‘Surname’, ‘First name’ and ‘Bank account number’.

Personal details – This is the account that needs to be reimbursed

The address of the charging station location is the same as the address below*

Yes – The address fields are the same. I will leave the address fields below blank.

No – The address fields are different. I will fill in the address fields below.

Surname*

First name*

Phone number*

Personal email address*

(this email address will serve as your login)

IBAN bank account number*

(this account will be used to deposit your reimbursable charging sessions)

Street name

House number

Postal code

City / village

Country

Company details – This is the account that needs to do the reimbursement

Company name*

Company type*

(e.g. private limited company, public limited company, sole proprietoship etc.)

VAT number*

Name & first name of the company contact person*

Company street name & house n°*

Company postal code & city*

Company phone number*

Email address of the company contact person*

(this email address will also serve as a login, but must be different from the personal email address provided earlier)

Email address of the company billing department

(If different from the login email address above)

Charging station for professional use – At what price do you want to reimburse your employees?

Your reimbursement rate can be based on the CREG tariff (recommended) or on a self-chosen tariff (not recommended). Please note that the end user (depending on his mobility provider) may have to pay additional costs when using your charger. You can always adjust the reimbusement rate in the Mobiflow platform later, if the charger seems to be priced too high or too low compared to other chargers in the region.

Please choose your reimbursement tariff:*

CREG tariff (recommended)

Self-chosen tariff (not recommended)

If you opt for the self-chosen tariff, please fill in the tariff of your choice in the field below.

Self-chosen tariff (price/kWh)

Professional contract

I want to order a Professional contract for € 7 / month excluding VAT (for each connector):*

Yes

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy

Terms of services
Privacy policy

Charging card – professional contract

Do you already have a charging card(s)?*

Yes

Yes, I already have a charging card(s)

I have one or more charging cards. The charge card number(s) are as follows:*

(BE-MBF-xxxxxxxx-xx) (please separate the different charging card numbers with commas)

No, I don’t have a charging card yet and would like to order one or more

Your first charging card per unique user is completely free! For additional charging cards, we charge a one-off fee of €10 per charging card per user. For example, if you want 2 charging cards for the same user, you pay € 10 extra.

How many charging cards do you want to order?*

In case you wish to order several charging cards, please note the name, first name and email address of the user for each charging card below.

Charging station for public use – Charging station information

Charging station brand*

Charging station(s) serial number(s)*

Charging station location: Street name*

Charging station location: House number*

Charging station location: Postal code*

Charging station location: City / village*

Charging station location: Country*

Where is the charging station installed?*

Against the building

Separate from the building, e.g. in a car park or parking area

Name of the installation company*

Charging station for public use – Energy contract

Here we want to know who needs to be reimbursed for the charging sessions at the charging station.

Who pays the electricity bill of the house/building to which the charger is connected?*

The electricity bill is paid by an individual.

The electricity bill is paid by a company.

In other words, who owns the contract with the energy supplier?

Charging station for public use – Personal information

If this address information corresponds to the address details of the charging station that you have just filled in, you do not need to fill them in again, with the exception of the fields ‘surname’, ‘first name’ and ‘bank account number’.

The address of the charging station location is the same as the address below*

Yes – The address fields are the same. I will leave the address fields below blank.

No – The address fields are different. I will fill in the address fields below.

Surname*

First name*

Phone number*

Email address*

(this email address will serve as a login).

IBAN bank account number*

(this account will be used to deposit your reimbursable charging sessions and for paying the licence fee, for which you will need to set up a payment mandate. We will be happy to explain to you how to do this after we have created your account)

Street name

House number

Postal code

City / village

Country

Do you want to integrate a split billing functionality into the software of your charging station? Split billing enables splitting the charging costs of your vehicle from the household energy consumption and invoicing your employer or company for these costs directly.*

Yes

Charging station for public use – information relating to the company

Name of the company*

Typ of company

(e.g. private limited company, public limited company, sole proprietorship etc.)

VAT number*

Surname of the contact person of the company*

First name of the contact person of the company*

Street name of the company*

House number of the company*

Postal code of the company*

City / village of the company*

Country of the company*

Phone number*

E-mail address of the contact person of the company*

(this e-mail address will serve as a login)

Billing email address:*

IBAN bank account number*

(this account will be used to deposit your reimbursable charging sessions and for paying the licence fee, for which you will need to set up a payment mandate. We will be happy to explain you how to do this after we have created your account)

Charging station for public use – At what price do you want to make your charging station available?

You can compose your reimbursement rate based on one or a combination of the following three elements, depending on the intended use of the charger. Please note that the end user (depending on his mobility provider) may have to pay additional costs when using your charger. You can always adjust the reimbusement rate in the Mobiflow platform later, if the charger seems to be priced too high or too low compared to other chargers in the region.

Starting fee*

(one-off fee when starting the charging session; when no fee is to be set in this field, please enter a “0” for value)

Price/kWh*

(price you pay to your energy supplier, which may or may not be increased to have a margin on the sale of the charging sessions; when no fee is to be set in this field, please enter a “0” for value)

Hourly fee*

(rarely applied in Belgium; it implies an additional cost charged per hour; when no fee is to be set in this field, please enter a “0” for value)

Charging station for public use – AC or DC

AC = Alternating Current
DC = Direct Current

Select one of the options below*

It is a standard AC charging station.

It is a DC fast charger. High power voltage is required (high-voltage cabin).

Public contract – AC charging station

I want to order a Public AC contract for € 9.5 / month excluding VAT (for each connector):*

Yes

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy

Terms of services
Privacy policy

I want to order a Public DC contract for € 12.5 / month excluding VAT (for each connector):*

Yes

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy

Terms of services
Privacy policy

Charging card – public contract

Do you already have a charging card(s)?*

Yes

Yes, I already have a charging card(s)

I have one or more charging cards. The charge card number(s) are as follows:*

(BE-MBF-xxxxxxxx-xx) (please separate the different charging card numbers with commas)

Do you want the charging card(s) to be added to the white list of the charging station so the owner of the card(s) is able to charge for free?

Yes

No, I don’t have a charging card yet and I would like to order one or more cards

How many charging cards do you want to order?*

In case you wish to order several charging cards, please note the name, first name and email address of the user for each charging card below.

Do you want the charging card(s) to be added to the white list of the charging station so the owner of the card(s) is able to charge for free?*

Yes

Thank you, all questions are now filled in!

Don’t forget to click ‘Submit’ so we can create your account. Our team will contact you as soon as your account has been created, so you can set up your payment mandate. How you can do this, will then be explained in more detail.

We are constantly striving to improve and would therefore welcome your feedback on this form. We appreciate your comments and would like to thank you in advance

Providing that your employer is a Mobiflow customer, your employer or fleet manager will be able to send you an invitation for the reimbursement of your home charging sessions. You will also receive your charging card through your employer or fleet manager. If you have not yet heard from your fleet manager or employer, please contact them.

By sending the form, we ensure that your charging station is created correctly in the Mobiflow platform. Only after accepting the split billing invitation from your employer, your home charging sessions will be reimbursed. If you have any questions regarding this, you can always reach us at info@mobiflow.be or by calling +32 9 296 45 45.

Terms of services and privacy policy*

I have read and I agree to the terms of services and the privacy policy

Terms of services
Privacy policy

We are constantly striving to improve our processes and would therefore welcome your feedback on this form. We appreciate your comments and would like to thank you in advance: