1. Please fill out the questions below.

I pledge to ride my bike at least once during the week of May 17 - 21.

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* 1. Full Name

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* 2. Home Address

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* 3. City

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* 4. Zip

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* 5. E-mail

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* 6. Home Phone

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* 7. Employer (worksite, school) Name:

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* 8. Employer Address

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* 9. City

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* 10. Zip

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* 11. Round Trip Commute Miles:

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* 12. How do you usually get to work?

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* 13. Will this be your first bicycle commute?

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* 14. Will you connect to a bus or train on your bike trip to work?

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* 15. Which Day(s) will you ride your bike?

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