UBP Open Shop Compensated Usage Form

The open shop compensated usage program allows individuals in need to receive free used parts and compensated shop time in order to maintain their bicycle. Applicants are allowed to maintain one bicycle through the program. If the bicycle is stolen, missing, or damaged beyond repair there may be a waiting period before a new bicycle can be worked on. The program provides essential parts required for safe operation of the bicycle. Volunteers and staff will choose these parts from UBP’s selection of used parts. UBP will ask participants for a donation of any amount that is meaningful to the applicant.

Have you received a Free Bike from us as part of the Free Bike Program?

This is a required question

Last Name

This is a required question

First Name

This is a required question

Street Address

This is a required question

City

This is a required question

State

This is a required question

Zip Code

Zip code must be a number

This is a required question

Are you homeless or living in transitional housing?

No
Homeless
Shelter or transitional housing (Examples are YMCA/YWCA, Sojourners Place, Sunday Breakfast Mission, etc)
Other:

This is a required question

Sources Of Income

Please check any that apply

AFDC/TANF (Aid to Families with Dependent Children, Temporary Assistance for Needy Families)
GA (General Assistance)
SS (Social Security)
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
Wages
Unemployed
Other:

This is a required question

Do you participate in any of the following programs?

Check any that apply

Food Stamps
Medicaid
Probation
Work Release

This is a required question

Please Estimate Your Annual Household Income

Annual Income must be a number

This is a required question

Household Size/Household Annual Income

To be eligible your annual household income must be lower than the listed amount for household size.

This is a required question

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?

This is a required question

What forms of transportation do you currently use?

Check any that apply

This is a required question

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.

This is a required question

Information about your bicycle - Brand/Make

The compensated usage program is for maintaining one bicycle per applicant.

This is a required question

Model

This is a required question

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.

This is a required question

Color

This is a required question

Condition of the bicycle

This is a required question

Would you like to sign-up for our E-mail list to learn about events & announcements??

If yes, put your email address here:

This is a required question

Are you interested in volunteering?

Yes (Volunteer orientation is on the first Monday of each month at the shop)
No

This is a required question