First Name:______________________________________________
Last Name:_______________________________________________
Local Street Address:______________________________________________________
Apt./Box No.:__________
City:______________________________ State:_________ ZIP:___________________
Email:_________________________________________________________________
Phone:_________________________________________________________________
Type of membership (circle one):
Standard 12-month Membership, $40.00
Student/Low-income 12-month Membership, $25.00
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