Are you homeless or living in transitional housing?
Sources Of Income
Please check any that apply
Do you participate in any of the following programs?
Check any that apply
Please Estimate Your Annual Household Income
Your answer
Household Size/Household Annual Income
To be eligible your annual household income must be lower than the listed amount for household size.
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Self-Certification *
Do you certify that your annual gross income is at or below the income listed on this form for households with the same number of people as your household, OR that your household participates in the programs that have been checked on this form?
What forms of transportation do you currently use?
Check any that apply
Do you have children that you would like to be able to participate with you in the Compensated Usage program?
You must accompany and supervise your children the entire time they are in the shop.
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Information about your bicycle - Brand/Make
The compensated usage program is for maintaining one bicycle per applicant.
Your answer
Model
Your answer
Serial Number
Serial numbers are usually located under your bottom bracket and are a combination of numbers that sometimes includes letters. Please ask a volunteer for help if you cannot find your serial number.
Your answer
Type of bike
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Color
Your answer
Wheel size
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Condition of the bicycle *
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