1.Nominee name

2.Nominee employer

3.Employer address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

4.Commute starting location

5.How long has this person been commuting by bike?

6.Does this person commute by bike year round?

7.Does this person's employer provide bike incentives? (Check all that apply)

Bike racks

Clothing lockers

Showers

Subsidy

Other (please specify)

8.Why did you nominate this person?

9.Tips or recommendations for other people interested in biking to work?

10.Do you know of any health benefits this person noticed?

11.Your name

12.Your email

13.Your phone number