Be sure to fill out this application completely and ensure the information is accurate.

1-6. Owner's Contact Information

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Be sure to fill out this application completely and ensure the information is accurate. 1-6. Owner's Contact Information

1a. Last Name	1b. First Name	1c. Middle Init
2. Permanent Address	3. City	4. State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip Code	6a. Permanent Phoneext.	6b. Local Daytime Phoneext.
6c. Email Address

7a. Serial Number - This is the most important identifying feature of your bicycle. It must be included for best results if your bicycle is stolen. This number is unique to the bicycle and is found on the bicycle’s frame. See diagram below for the most common serial number locations. 

Serial Number

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7a. Serial Number - This is the most important identifying feature of your bicycle. It must be included for best results if your bicycle is stolen. This number is unique to the bicycle and is found on the bicycle’s frame. See diagram below for the most common serial number locations. Serial Number

8a. Manufacturer - This name should be on the front of the bicycle’s head tube (see diagram on right). Examples are Schwinn, GT, Huffy, Trek. 

Manufacturer

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8a. Manufacturer - This name should be on the front of the bicycle’s head tube (see diagram on right). Examples are Schwinn, GT, Huffy, Trek. Manufacturer

8b. Model - This is the secondary name for the bicycle. Examples include Varsity, Mojave, Gulch, Ironman, 730. 

Model

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8b. Model - This is the secondary name for the bicycle. Examples include Varsity, Mojave, Gulch, Ironman, 730. Model

9a. Frame Type (Check One) - Check the frame type. Note: Mountain bike and BMX are not frame types but descriptions of the type of bicycle; use Bicycle Type (9b).

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9a. Frame Type (Check One) - Check the frame type. Note: Mountain bike and BMX are not frame types but descriptions of the type of bicycle; use Bicycle Type (9b).

Diamond/Men's	Recumbent
Tricycle	Step-Through/Women’s
Tandem	Other

9b. Bicycle Type (Check One) - Indicate the type of bicycle. If you are unsure, leave blank.

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9b. Bicycle Type (Check One) - Indicate the type of bicycle. If you are unsure, leave blank.

Mountain Bike	Road/Touring
Cruiser	Hybrid
BMX	Other

10a. Other Description (optional) - Optional. Indicate any unique identifying features such as baskets or decals.

10a. Other Description (optional) - Optional. Indicate any unique identifying features such as baskets or decals.

10b. Wheel Size - Indicated on the sidewall of the tire. An example of a wheel size on the tire is 27 x 1.25". Circle 27 as the wheel size in this case. Mountain bikes typically have 26 inch tires, hybrids and road bikes have 700c.

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10b. Wheel Size - Indicated on the sidewall of the tire. An example of a wheel size on the tire is 27 x 1.25". Circle 27 as the wheel size in this case. Mountain bikes typically have 26 inch tires, hybrids and road bikes have 700c.

mountain/hybrid/road: 26"	mountain/hybrid/road: 27"
mountain/hybrid/road: 27"	mountain/hybrid/road: 27"
child/teen/small adult: 12"	child/teen/small adult: 14"
child/teen/small adult: 16"	child/teen/small adult: 20"
child/teen/small adult: 24"	Other If other, type text here.

10c. # of Speeds - Indicate number of speeds or gears on your bicycle. To find how many speeds your bicycle is, multiply the number of chainrings (by your pedals) by the number of cogs on your rear wheel. Common speeds include 16 (2 x 8) and 27 (3 x 9). 

# of Speeds

10c. # of Speeds - Indicate number of speeds or gears on your bicycle. To find how many speeds your bicycle is, multiply the number of chainrings (by your pedals) by the number of cogs on your rear wheel. Common speeds include 16 (2 x 8) and 27 (3 x 9). # of Speeds

11. Frame Size - See diagram below for more details. Measure from the top of the seat tube (not the seat or seat post) to the center of the bottom bracket (crank). Round to the nearest half-inch or centimeter. Frame sizes for an adult are typically between 14 and 23 inches, or 35 and 60 centimeters. 

Frame Size

11. Frame Size - See diagram below for more details. Measure from the top of the seat tube (not the seat or seat post) to the center of the bottom bracket (crank). Round to the nearest half-inch or centimeter. Frame sizes for an adult are typically between 14 and 23 inches, or 35 and 60 centimeters. Frame Size

11. Frame Size - See diagram below for more details. Measure from the top of the seat tube (not the seat or seat post) to the center of the bottom bracket (crank). Round to the nearest half-inch or centimeter. Frame sizes for an adult are typically between 14 and 23 inches, or 35 and 60 centimeters. Frame Size

inches

meters

12. Color - If the bicycle has one predominant color, write that color under “1st Color” and leave “2nd Color” blank. If the bicycle has two colors, write the most predominant as the “1st Color” and the secondary color as the “2nd Color”.

12. Color - If the bicycle has one predominant color, write that color under “1st Color” and leave “2nd Color” blank. If the bicycle has two colors, write the most predominant as the “1st Color” and the secondary color as the “2nd Color”.

1st Frame Color

2nd Frame Color

By completing this form, I hereby certify, under penalty of law, that I am the lawful owner of the above described bicycle. 

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By completing this form, I hereby certify, under penalty of law, that I am the lawful owner of the above described bicycle.

Signed

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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