DASB Bicycle Request Form
DASB Bicycle Request Form.docx Revised 10/1/2019
STUDENT WHO WILL PICK UP THE BICYCLE MUST COMPLETE THIS FORM
All applicants must meet the following conditions to qualify.
• Be 18 years of age or older
• Have paid all College fees in full or enrolled in an installment payment plan
• Be a DASB member (pay the DA Student Body Fee)
• Be enrolled in at least six (6) units at De Anza College
Full Name Student ID #
Cell Phone Home Phone
Email Address
Height
I authorize the Office of College Life to check my academic record to verify eligibility to be awarded use
of a DASB Bicycle.
Signature Date
If you qualify for the program and bikes are available, you will be contacted to come into the Office of
College Life to pick up the equipment and sign necessary documents.
NOTE:
• Rental period is for one quarter only
• Student will be responsible for lost, stolen, missing equipment provided to them
• Student will be responsible for the cost of replacement of each item provided and/or the cost of
repairs if needed. Failure to return equipment or reimburse the DASB for any needed repairs or
replacement, by the agreed upon date and time, will result in an academic hold being placed on
my De Anza College record and/or referred to the appropriate De Anza College Manager for
disciplinary actions.
• Late Fee:
There will be a $5 late fee for every business day that the bike is not returned after the
agreed upon date with a $30 maximum.
• Costs of replacement:
Bicycle $300, Bicycle Lock/Key $33, Bicycle Helmet $38, and Bicycle Corral Key $10.
For College Use Only
6 or More Units Fees DASB Member 18 or over
Verified by:
DASB Bicycle Program Coordinator Staff Signature Date
