Congratulations on your wise investment for Your Electric Bicycle! Please fill out this form then click the "submit" button on the end of this page to proceed to the next page!
If you want to reserve our today's low price and want us to charge your account or ship this product at a later time -up to 90 days- please take a note:
Information about You as the Purchaser
(shipping address may be different if wanted as shown on the next page)Billing address
First name Last name
Street address City
State ZIP
Telephone with area code (home phone) email
Shipping address (leave blank if same as the billing address)
First name Last name
Street address City
State ZIP
Telephone with area code email
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Payment information - choose below
Option One: pay by check electronically Click here why!
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Bank Name: |
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Routing umber: (must be 9 digits) |
Account number: Confirm Account number: |
Check number: (upper right corner) |
Option Three: fax us your order:
1. Fill out the order form above using your check
2. Print out this form
3. Fax it to us at 203-741-1040 (24/7, anytime)
Why not credit cards?
(CLICK the Submit button, then please wait a few seconds for the page to upload)
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