2023 BIKETOWN For Business Enrollment Form

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Email *

Organization Name *

Check the box to confirm your subsidy amount. *

Full Subsidy (Organization pays $75 per employee + tax)

Partial Subsidy (Organization pays $40 per employee + tax, Employee pays $40 + tax)

Required

Address 1 *

Address Line 2

City *

State *

ZIP *

County *

How many employees does your organization have in Portland? *

Program Manager Contact Information

This person is the primary contact for the account.

Program Manager Name *

Program Manager Job Title *

Program Manager E-mail *

Program Manager Direct Phone *

Secondary Contact Information

Optional: This person is the secondary contact for the account.

Secondary Contact Name

Secondary Contact Job Title

Secondary Contact E-mail

Secondary Contact Direct Phone

Accounts Payable Contact Information

This person receives monthly invoices.

Accounts Payable Name *

Accounts Payable Job Title *

Accounts Payable Email *

Accounts Payable Direct Phone *

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