Please complete the form below.

Disclaimer: This form is intended to pre-qualify potential participants to Pueblo's "e-Cycle-To-Own" program and does not gaurantee an automatic award for an e-bike. Program mechanics will follow. 

NOTE:
Attach copies of 1) proof of income like your latest W-2, certificate of employement, or pay stub and 2) proof of residence like a utility bill, bank statement, etc. to this application. 

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* 1. Full Name

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* 2. Complete Address

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* 3. Employer

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* 4. Employer's Complete Address

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* 5. Job/Nature of Work

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* 6. Latest Annual Income as of Year 2020

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* 7. Current Mode of Transportation to Work

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* 8. What is your age?

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* 9. What is your gender?

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* 10. What is your Race?

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* 11. If a refundable deposit of $150.00 is required, are you able to provide that in exchange to owning an e-Bike?

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* 12. Do you have a covered, safe, and secure e-Bike storage location at home?

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* 13. Will you have a covered, safe, and secure e-Bike storage location at work?

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* 14. Will you participate in mandatory safey, traffic, and maintenance training courses?

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* 15. Are you willing to participate in any required data collection or survey (smart phone required)?

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* 16. Please upload your proof of income; This could be your latest W-2, a certificate of employment, or pay stub. 

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* 17. Please upload your proof of residence; This could be a utility bill, bank statement, etc.

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* 18. Please Add Your Contact Information

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