Bublr Bikes Access Pass

JavaScript tidak diaktifkan pada browser, jadi file ini tidak dapat dibuka. Aktifkan dan muat ulang.

The Bublr Bikes Access Pass is a program that allows qualifying residents who possess a food share benefits card, receive Medicaid or SSI benefits, or are residents of Section 8 housing, to receive a discounted Bublr Bikes Annual Membership (traditionally $100)

Please fill out this form so we may determine your eligibility. After submitting the form and payment you will be mailed a special Access Pass Card that you can use at any Bublr Bikes Station to check out a bike.

--------------------------------------------------------------------------------------------------------------------------------------

Pass type: ANNUAL PASS (365 days Rain/Snow or Shine)

COST: The Bublr Bikes Access Pass is currently available for FREE thanks to Anthem Blue Cross Blue Shield!

TRIP TIME: Members with this annual pass type are allowed to take trips up to 60 MINUTES at a time. Checked your bike in after 60 minutes of riding? No problem, you can check the Bublr Bikes right back out again and keep riding! You can take as many 60 minute Bublr Bike trips daily/weekly/monthly/yearly as you like as long as you honor the pass type TRIP TIME ALLOWANCE.

Funding for this program is provided by Anthem Blue Cross Blue Shield.

Do you receive Foodshare, Medicaid, SSI, or live in Section 8 Housing? (check all that apply) *

Foodshare

WIC

Medicaid

Supplemental Security Income

Live in HACM Housing

Wajib diisi

If you receive Medicaid please let us know your Medicaid Insurance Provider *

Anthem Blue Cross Blue Shield

Badger Care Plus

Network Health

United Healthcare

ICare

Molina

Forward Health

Humana

Children's Community Healthcare

Other

I qualify in a way other than Medicaid

First Name *

Last Name *

Home Address *

Zip Code *

Phone Number *

Email Address *

If you don't have a credit/debit card and need to sign up in person with a photo ID please check here.

I need to sign up in person.

Referred By: *

What does access to Bublr Bikes mean to you?

(Response is optional & may be shared as a testimonial to let our supporters know how their contribution makes an impact.)

Berikutnya

Kosongkan formulir

Jangan pernah mengirimkan sandi melalui Google Formulir.

Formulir ini dibuat dalam Midwest BikeShare, Inc.. Laporkan Penyalahgunaan

Formulir