I am interested in applying for the MCLiberty Bikeshare Program in Montgomery County. I understand that my
eligibility for the program must be confirmed and I hereby give permission for review of my financial information by
any County agency involved in this program, their contractors, and partner organizations.
I. PERSONAL INFORMATION (Please Print):
Name:_______________________________________________ No. of family members living with you:________
Street Address:______________________________________________________ Apt. No. ___________________
City:___________________________________________ State:_____MD______ Zip Code:_________________
Telephone (Home): ___________________ (Cell): _____________________ Work/Other Phone: ______________
E-Mail Address: _________________________________________________
II. EMPLOYMENT/JOB TRAINING/EDUCATION (Please Print)
I am currently employed. Proof of employment is required: _______________________________________________
________________________________________________________________________________________________
_________________________________________
(provide name, address and telephone number of employer)
I am currently enrolled in a job training program. Proof of current enrollment is required.
___ Montgomery Works Workforce Training Program (WIA)
___ CASA de Maryland Employment Program
___ Other job training (such as computer training, real estate, beauty/barber school).
Name: _________________________________________________________________________________
Address: _________________________________________________________________________________
Telephone No. ____________________________________________________________________________
I am currently a student. Proof of current enrollment is required: __________________________________________
(provide name of school)
III. INCOME CERTIFICATION
I certify that my family, and/or I, participate in one or more of the following programs for low income residents of
Montgomery County or other cities or counties in the Washington metropolitan region. Attach copy of program
participation letter, dated within 30 days. Please mark all that apply and add others not listed:
____ Food Supplement Program (Food Stamps) ____ Child Care Assistance
____ Temporary Cash Assistance (TCA) ____ Maryland Primary Adult Care Program (PAC)
____ Family and Children Medical Assistance ____ Supplementary Security Income (SSI)
____ MCPS Free or Reduced Meals (in schools) ____ Head Start Program
____ HOC Voucher Program ____ Rental Assistance
____ Maryland Energy Assistance Program ____ Latin American Youth Center Program (requires parental
permission to participate – ages 16-17 years of age)
____ Electric Universal Service Program
____ MANNA
____ OR ANY OTHER PROGRAMS that have an income eligibility requirement (please list below):
______________________________________ ________________________________________
Montgomery County Department of Transportation
MONTGOMERY COUNTY’S LIBERTY (MCLiberty)
BIKESHARE-A Free Program For Low Income Riders
Questions? Call 240-777-8380 - or - email us at:
mcdot.CommuterServices@montgomerycountymd.gov
