What do you wish to purchae?

1

Which Bike Would you like to purchase?

Cooly Grom - $1,999 (Pink, Rose Gold)

Cooly Cruiser Pro - $2,499 (Brown/Brown, Grey, Metallic Green, Brown/Black)

Cooly Ripper - $2,499 (Grey, Black, Dark Grey)

Cooly Cruiser Double Up: $2,799 (Black)

Sur-Ron Light Bee X 2025 - $7,299 AUD (Metallic Green, Phantom Purple, Black, Blue)

79Bike Falcon Pro Electric Dirt Bike - $7,499 AUD (Silver Purple, Black Purple, Black Red, Black Yellow, Silver Red, Silver Yellow)

Rerode R1 - $6,499 AUD (Available in Black, Red, Dark Grey)

Rerode R1+ - $7,499 AUD (Available Available in Red, Black, Yellow)

Surron Ultra Bee - $9,990 AUD

2

Name

Title

First Name

Last Name

4

E-mail* This field is required.

example@example.com

5

Phone* This field is required.

6

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

What is your status at your current address?

Renting

Mortgaged

Owned Outright

Boarding / Living with Fmaily

8

Current Employer

9

Occupation

10

Employment Status

Casual

Full Time

Part Time

Self Employed

11

Years of experience

0-1 Year

1-2 Years

3-4 Years

5+ Years

12

What are you paid Weekly?

13

Anything you wish the broker to know

14

What time would you like broker to call you?

15

I hereby agree that the information given is true, accurate and complete as of the date of this application submission.

YES