Submit Ticket: Assistance Request

First name

Last name

Email

Phone

Address

Age

Gender

Male

Female

Prefer not to share

Height (approx)

Referred by or

Do you know how to ride a bike?

Yes

Yes, but it has been a while.

No

Your answer will allow us to provide you with additional resources if needed.

Race:

Housing/Living Situation

Sources of Income

Are you currently a student?

Yes

No

Taking time off

Select all that apply to you.

Your Current Method of Transportation

What destinations do you most find difficult to travel to?

Are you capable of investing in the maintenance an eBike?

Yes

No

What is your monthly maintenance budget? (Subscription based maintenance or self-financed)

$10

$20

$50

Other

Share Your Transportation Challenges:

Additional Information Regarding Your Need

Empowering through mobility.