Request A Bicycle

Are you making this request on behalf of someone else?(Required)

Yes

No

Fill this section with details of who needs the bicycle

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address City County PostCode

Please indicate what income-related benefits you currently receive:(Required)

Income Benefit Evidence(Required)

Accepted file types: jpg, docx, png, pdf, Max. file size: 256 MB.

Please upload evidence of your income benefits for the last three months

Fill this section if you are making the request for someone else.

Third Party Name(Required)

First Last

Third Party Email(Required)

Third Party Phone(Required)

Type of Relationship(Required)

Other Relationship(Required)

Is this a professional relationship?

Yes

No

Organisation Details

Fill this section if the type of relationship is a professional one

Organisation Name(Required)

Organisation Email(Required)

Preferred Contact Method(Required)

Email

Phone

SMS

Preferred Contact Time(Required)

Morning

Afternoon

Evening

Phone

This field is for validation purposes and should be left unchanged.

01.

Request Bicycle

02.

Wait for Confirmation

03.

Collect your Bicycle

04.

Attend a brief training

Fill the bicycle request form

Organisation Details

Hours

Contact

info@up-cycled.co.uk