Bike Application
Lighthouse Community Center
Today's Date
*
-
Month
-
Day
Year
Date
Applicant Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Proof of ID
*
Yes
No
Do you have a bike lock?
*
Yes
No
Approximate Height (Feet, Inches)
*
Employment Status
*
Not employed
Disabled
Part-time
Full-time
Are you receiving any sort of income?
*
Yes
No
If Yes, please explain.
How will having a bike benefit you?
*
By signing this application, you (the applicant) verify that all information is accurate and correct. The applicant agrees that they will provide their own means of securing the bicycle. Additional proof of a bicycle lock may be requested upon the discretion of the service provider by the applicant presenting the lock at the time of receiving the bicycle. Any maintenance by the service provider will be for a fee of an amount at the discretion of the service provider. Failure to receive the applicant’s bicycle at the pick-up date may result in the forfeiture of services and/or require a new application.
Signature
*
Submit
Should be Empty: