Portland Clean Energy Community Benefits Fund e-bike rebate applicant registration form

Thank you for your interest in the Portland Clean Energy Community Benefits Fund e-bike rebate program! The information you provide below will be used to ensure your eligibility and provide you with the best possible experience. Rest assured, your data is handled with utmost care and confidentiality. We prioritize your privacy and guarantee that your information will not be shared with any third parties. Information provided in this form will be verified before a rebate is issued. Thank you and we look forward to helping you enjoy the benefits of our program.

PERSONAL INFORMATION

First Name

Last Name

Date of Birth

Mobile Phone

Preferred Language

Unhoused or No Permanent 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 portlandebikes@aptim.com or call 503-563-0624.

Full Address

Please keep in mind that the address suggestion may not always match the one you have exactly (for example, the apartment number or street direction might be different). If you're having trouble, please contact customer service for assistance by email at portlandebikes@aptim.com or call 503-563-0624.

Street

County

City

Postal Code

State/Province

Home Phone

ELIGIBILITY INFORMATION

Share income information

This program is only open to income-qualified residents. You will need to share your annual household income to be considered.

NoYes

Total Household members

Annual Household Income

Income and household information required to determine which rebate you can apply for. 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 during the random selection process.