Earn-A-Bike Application
Please fill out this form entirely. If a field does not apply, please write 'N/A'.
What is your current mode of transportation
Do you currently own a bike? *
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
ZIP Code *
Your answer
Height *
Your answer
Weight
Your answer
Email Address *
Your answer
Phone Number *
Your answer
What will bike be used for?
Your answer
How often will you use the bike
Specific Requests
Your answer
How would you prefer us to contact you? *
Required
How did you hear about WellBuilt Bikes?
Your answer
What days of the week are you available for community service?
What hours of the day are typically best for you to do your hours? (hours are typically done in 2.5-5 hour blocks)
Your answer
Do you require any special work related accommodations?
Your answer
Are you interested in joining us on group rides?
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