CyclErie DR0514

Qualified Purchaser of an Electric Bicycle Affidavit
Full Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Street Address*
City*
State*
ZIP Code*
Proof of Colorado residency is required. If available, please provide a current, unexpired Colorado driver license or Colorado identification card number in the box below.
Colorado Driver's License Number*
I attest that I am a Colorado resident who has not previously purchased a qualified electric bicycle
Signature*
Date (MM/DD/YY)*

MonthDayYear
Date
Should be Empty: