First Name*

Last Name*

City*

Email*

Gender*

Female
Male
Neither/Prefer Not to Say

Age*

Income*

Less than $20,000
$20,001 - $50,000
$50,001 - $80,000
$80,001 - $110,000
$110,001 - $140,000
$140,001+
Prefer Not to Say

Highest level of education completed*

High School Diploma
Trade Certificate
Undergraduate/College Degree
Graduate/Professional Degree
Prefer Not to Say

How did you hear about Plug'n Drive*

Are you in the market for an electric vehicle?*

Yes
No
Undecided

Please rank the following factors influencing your decision to purchase an electric vehicle

Most Important*

Second Most Important*

Third Most Important*

COVID19 Operations

The EV Discovery Centre and Mobile EV Education Trailer (MEET) are open on an appointment-only basis. In response to the COVID-19 pandemic, a number of operational procedures have been put in place. All visitors must submit this health declaration form under their name prior to their visit. In the case of children under the age of 16, a health declaration must be submitted on their behalf by a legal parent or guardian. A face mask that covers your nose, mouth and chin is mandatory for the duration of your visit and six feet physical distancing is enforced where possible.

Completion of this declaration form does not guarantee that you will not contract the COVID-19 virus during your visit. This is a risk that every visitor must assess for themselves and, if you choose to visit, you agree to accept the risk of either contracting or transmitting the virus.

Thank you for your cooperation and for helping us maintain a sanitary environment for yourself and future guests.

I hereby declare that neither I, nor anyone in my household, has been diagnosed with, (or is expected to have), COVID-19 and/or experienced any cold or flu like symptoms in the last 14 days, including: fever, cough, sore throat and/or respiratory distress. If I, or anyone in my household, is diagnosed with, (or is expected to have), COVID-19 and/or experiences any of these symptoms after I submit this declaration, I will not visit the EV Discovery Centre or MEET for a minimum period of 14 days after the symptoms have completely gone away.*

I hereby declare that neither I, nor anyone in my household, has returned from a country outside of Canada in the past 14 days. If I, or anyone in my household, returns from a country outside of Canada after submitting this declaration, I will not visit the EV Discovery Centre or MEET for a minimum period of 14 days after the return date.*

I hereby declare that I have read and understand Plug'n Drive's COVID-19 Operational Protocols and Guidelines and agree to comply by any and all visitor responsibilities laid out therein. The guidelines can be found on our main website at plugndrive.ca/covid19-protocols.*

If you are submitting this declaration on behalf of a dependent as the legal parent or guardian, please indicate the name/s of any dependents.

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