2. Essential Bikes Candidate Application
4. 
5. Please Note:
   This application is meant only for individuals that require an Essential Bike as a primary form of transportation. Only one bike will be given per applicant. You will not get a bike if you have already received an Essential Bike before.
7. Name*
8. Today's Date*
10. Street Address*
11. City*
12. State*
14. Phone Number*
15. Date of Birth*
17. Height*
18. Weight*
    (in lbs)
20. E-Mail
22. Employer
24. Reference (i.e. church, boss, etc.)*
25. Reference's Phone Number
27. Description of Need*
    To help us determine the right bike for you, in 300 characters or less, please tell us why you need a bike and describe the distance and route you often travel or will need to travel.
29. Rules and Regulations
    Bike must remain locked at all times when not in use - a bike lock will be provided to you. Bike cannot be sold or gifted to another party. You must follow all bike rules of the road, such as:riding on sidewalks is acceptable except downtown and Aggieville, you must have lights (provided by program) to ride after dusk and before dawn, you must obey traffic signs and signals.
31. Electronic Signature*
    By signing this document, you agree to care for the bicycle given to you and follow the instructions listed above at all times. If you fail to follow the rules of this program, it is possible the program will request the bicycle back from you.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field