E-Bike Rebate Applicant Registration Form

Thank you for your interest in the Bentonville E-Bike rebate program! The information you provide below will be used to ensure your eligibility and provide you with the best possible experience. If you would like to apply for an income qualified rebate, you will need to share your income information below. 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

Full Address

Street

County

City

Postal Code

State/Province

Home Phone

Phone Number

Preferred Language

ELIGIBILITY INFORMATION

Annual Household Income

Income and household information is used 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. If you choose not to share your income information you will be directed to the General Resident application.

Total Household members

Share income information

NoYes

What type of E-Bike are you interested in?

DISABILITY SECTION

Do you have a disability or chronic illness that requires an adaptive e-bike?

NoYes