BOSTON E-BIKES INCENTIVE PROGRAM APPLICANT REGISTRATION FORM

Thank you for your interest in the Boston E-Bikes Incentive Program!
The information you provide below will be verified to ensure your eligibility. We prioritize your privacy and guarantee that your information will not be shared with any third parties.

PERSONAL INFORMATION

First Name

Last Name

Date of Birth

Full Address

Street

County

City

Postal Code

State/Province

Home Phone

Mobile Phone

Preferred Language

ELIGIBILITY INFORMATION

Share income information

Income and household information is used to determine which voucher you can apply for.

NoYes

Annual Household Income

Enter the gross annual income for your entire household. Please ensure this is accurate as you will be required to provide proof of income if selected. If you choose not to share your income information, you will be directed to the application for a non-income-eligible voucher.

Total Household members

Are you applying for a Powered Handcycle Wheelchair Attachment or Adaptive E-Bike?

Please check yes if you are an adult with a chronic or permanent disability who is looking to buy a Powered Handcycle Wheelchair Attachment or Adaptive E-Bike modified to their needs.

NoYes