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Submit Ticket: Assistance Request

Gender
Male
Female
Prefer not to share
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
Own Home
Rent Home/Apartment
Transitional Housing
Homeless
Other
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?
What is your monthly maintenance budget? (Subscription based maintenance or self-financed)
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