First Name:______________________________________________
Last Name:_______________________________________________
Local Street Address:______________________________________________________
Apt./Box No.:__________
City:______________________________ State:_________ ZIP:___________________
Email:_________________________________________________________________
Phone:_________________________________________________________________
Donation (please circle one):
$15.00
$40.00
$125.00
$450.00
Other $____________
Amount enclosed:___________________________________________________
How did you first hear of the Bike Co-op? (poster, web site, friend, radio ad, etc.)
_______________________________________________________________________
Date:________________________________
Mail (with payment, a personal check or money order made out to "UCIMC/The Bike Project") to:
The Bike Project
202 S. Broadway Ave, #24
Urbana, IL 61801