BluePrint Bikes!
application form to receive a re-purposed bicycle
What kind of bike are you looking for? *
This bike will be used primarily for.... *
What is your annual household income (before taxes)? *
How many people live in your household (including yourself)? *
Do you receive any financial assistance (TANF, WIC, SNAP, HEAP)? *
Required
Please read the following statements and a check the box if you agree: *
Required
Please provide your contact information so that we can notify you if a suitable bike is available. Let's begin with your name: *
Email address and/or phone number: *
Address (this program is for Geneva residents only): *
Name of the person who will be riding this bike (if different than the applicant):
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