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2. 
4. Date of Application*
   Date of Application
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Fax Number
18. Email Address*
20. Make and Model of E-Bike(s):*

    Please list make and model # of E-Bike purchase(s)

23. Where and when did you purchase your E-Bike? *
25. Do you have a receipt of purchase?*

    1. Yes
    2. No
26. Upload E-bike receipt(s) here*

    Please upload your receipt(s) here. 

28. Check (will be mailed to address listed above)*

    1. elittlefield@forestgrove-or.gov

    Upon completing this agreement customer acknowledges the following:

    Incentive offer(s) may be changed or discontinued at any time by FGL&P.  FGL& P reserves the right to inspect product(s). 

    I understand the above and certify that I am a current customer of FGL&P.

30. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Electronic Signature*
34. Date*
    Date
36. Additional info.

    Submit completed form and email a copy of your receipt, which must show a purchase date and purchase price to: elittlefield@forestgrove-or.gov

38. Questions

    Email us at:  elittlefield@forestgrove-or.gov or call 503-992-3296

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field