Phone:(434) 924-7166
Fax: (434) 982-2817
Saferide: (434) 242-1122

2304 Ivy Road
P.O. Box 400214
Charlottesville, VA 22903-44790

Bike Registration Form

Please fully complete this form and click "submit" once complete.

* Required fields

U.Va. Affiliation:

First Name:

Last Name:

E-mail*:

Local Phone #:

Home Phone #:

Local Address:

Home Address:

Make of Bicycle:

Model of Bicycle:

Bicycle Serial Number*:

Bicycle Type:

Bicycle Color/ Description:

Bicycle Value: