Bike and Scooter Registration Form

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* 1. UVA Affiliation

UVA Student

UVA Faculty

UVA Staff

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* 2. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Local Phone Number

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* 6. Home Phone Number

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* 7. Local Address

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* 8. Home Address

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* 9. Make of Bicycle/Scooter

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* 10. Model of Bicycle/Scooter

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* 11. Bicycle/Scooter Serial Number

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* 12. Bicycle/Scooter Color and or Description

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* 13. Bicycle/Scooter Value