E-Bike Incentive Program Applicant Registration Form

Eligibility Check: The information you provide below will be used to ensure your eligibility and match you with the correct application for your location and personal circumstances. This form will determine which incentives you might qualify for and will direct you to the next steps in the application process. Information provided in this form will be verified before a rebate is issued. Your data is handled with utmost care and confidentiality. We prioritize your privacy and guarantee that your information will not be shared with third parties.

PERSONAL INFORMATION

Applicant Under 18

NoYes

First Name

Last Name

Date Of Birth

Enter your birthdate using the format MM/DD/YYYY. You must meet the age requirement to be eligible for this program.

Full Address

Begin typing your address into the box below, as you type a drop-down list of options will populate for you to select from. Please select your address when it appears. If you're having trouble, please contact customer service for assistance by email or phone at ebikeAR@aptim.com or 833-837-3826. Your address must be in the covered program area to be eligible for this program.

Street

County

City

Postal Code

State/Province

Home Phone

Preferred Phone

Preferred Language

Please select a language for email communications

Unhoused or No Permanent Residence

NoYes

If you do not have a residence, please provide an address where you can be contacted; this can be the address of an agency you are working with. If you cannot provide this, please contact customer service for assistance by email at ebikeAR@aptim.com or call 833-837-3826.

Pre Application State

Address Status

ELIGIBILITY INFORMATION

Income Document

Some voucher amounts are only available to qualified residents. Those applying for income-restricted vouchers will be asked to supply supporting documents if selected. Please select which document you will provide to show income eligibility if selected. If you are not applying for an income-based voucher, please select “I do not wish to share my income information.”

Total Household members

Enter the number of people in your tax household. This should be anyone included on your tax return. This does not include roommates or family members who file taxes separately.

Share income information

NoYes

Annual Household Income

Enter the adjusted gross income (line 11 on your tax return) for your entire household. Please ensure that this is accurate as you will be required to provide proof of income if selected during the random selection process.

Are you applying for an adaptive bicycle?

NoYes

Adaptive E-Bikes are specialized E-Bikes designed for use by individuals with disabilities who are unable to ride standard bikes. Please check yes if you have a disability that requires an adaptive E-Bike. This application type requires a letter from a medical professional.

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