* First Name
* Last Name
* Address
* City
* State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
* Zip Code
* Phone Number
email
* Place of Purchase
* Date of Purchase
How many products would you like to register? 1 2 3 4 5 6 7 8 9 10
Product 1: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial on kickstand plate Serial on Radish
Product 2: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 3: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 4: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 5: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 6: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 7: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 8: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 9: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
Product 10: FreeRadical Radish Surly Big Dummy Complete Surly Big Dummy Frameset Accessories name Price Serial Serial on Radish
What was your primary reason for purchasing this (these) Xtracycle product(s)? Car-Free Living Impress Friends Fun Commuting Pick up chicks/dudes Promoting your company Save money on transportation Protesting Just like to buy stuff Other:
What are you planning to do with your S.U.B. (Sport Utility Bicycle)? Touring Groceries Partying Kayaking Multi-sport Cruising Surfing Bike camping Courier Other:
Age
Sex Male Female
Occupation
Income
Do you consider yourself an environmentalist? Yes No
How did you hear about Xtracycle? Friend Web Media Bike shop Xtracycle Event Other:
What is your initial impression of this product and the service you've received so far?
Are you interested in hearing about becoming involved with our non-profit sibling, WorldBike? Yes No
Would you like to receive Xtracycle's newsletter by email? (We swear we will not sell your email address or you can hit us over the head with a FreeRadical) Yes No
Do you have any friends who'd like a catalog? Yes No
Name
Address
City
State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code