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2. Owner Name*
   Last, First, Middle Initial
3. Date of Birth
   Month/Day/Year
5. Address*
   Street Number & Street Name
6. Zip Code*
8. Owner Driver License Number/State
   If applicable
9. Home Phone*
10. Alternate Phone
12. Make/Brand
    EX: Schwinn, Trek, Redline
13. Model Name or Number
15. Style
    Mountain Bike, tandem
16. Wheel Size
17. Speed/Gears
18. Frame size
20. Color(s)
21. Brake System
    EX: Hand or Pedal
22. Serial Number*
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field