Name of Institution *

Department Name

Your Address *

City *

State *

ZIP / Postal Code *

Phone *

Email Address *

Type of Bicycle required *SelectCity / MTB bikes(Single speed)City / MTB bikes(Multi speeds)HybridRoad bikesElectric Bikes

Purpose of Bicycle Purchase *SelectEmployee UsageCharity donationGifting Purpose

Price range of Bicycle *

INR

Quantity Required *

Call back needed *YesNo

Call back Date

Call Back Time

Hours

Minutes

AMPM

Current Date

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