E-Bike Conversion Consent Form
Please complete this form to provide your consent and authorization for your bicycle's e-bike conversion. All fields are required to proceed.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Bicycle Make
*
Bicycle Model
*
Year of Manufacture
*
Select Desired E-Bike Conversion Plan
*
Standard Conversion (250W motor, basic battery)
Performance Conversion (500W motor, extended battery)
Custom Conversion (specify details below)
If selected Custom Conversion, specify details
I acknowledge my bicycle is in safe and roadworthy condition for conversion.
*
Yes, I confirm
No, please contact me
By signing below, I authorize the conversion work and acknowledge the associated risks and responsibilities.
*
Submit Consent
Submit Consent
Should be Empty: