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* 1. Which scheme are you interested in?

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* 2. Type of bike

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* 3. What is your height in feet and inches?
For example, if you are 5 feet and 4 inches, write 5’4”. This will help us match you to the right sized bike.

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* 4. Purpose of bike loan

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* 5. How do you normally travel to the following places?

  Walk Cycle Bus Motorcycle or scooter Train Car driver (alone) Car driver (with others) Car passenger Other (please specify)
Work
Education
Shopping/ Errand
Health (e.g. doctor)
Leisure

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* 6. Normally, how often do you travel by the following types of transport? (Please exclude half term and bank holiday weeks)

  Walk Cycle Bus Motorcycle or scooter Train Car driver (alone) Car driver (with others) Car passenger Other (please specify)
6-7 days per week
4-5 days per week
2 to 3 days per week
Once a week
Once a month
Less frequent/ Never

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* 7. What is your anticipated weekly loan bike mileage? 

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* 8. Number of adults in the household (17+):

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* 9. Number of children in household

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* 10. Number of bikes in the household

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* 11. Number of cars in the household

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* 12. How many people hold a licence in your household

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* 13. Your name

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* 14. What is your gender?

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* 15. Age

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* 16. Email

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* 17. Contact number

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* 18. Post code

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* 19. Who is your local authority?

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* 20. How did you hear about loan bike scheme

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* 21. I agree that by taking part in the loan bike scheme, my information will be shared with Better By Bike partners.

For more info, https://betterbybike.info/privacy

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