First Name:

Last Name:

Phone Number:

Email Address:

Address:

Post Code:

Date of Purchase:

Point of Purchase:
[select* pointofpurchase "EZEGO Website" "ACS Prestwick" "Atman UK" "Avon Valley Cyclery" "Bays Bikes" "Berkshire Cycle" "Bicycle Garage" "Bierspool Cycles" "Bike Chain Ricci" "Bike Pedlars" "Bike Pro Racing" "Blackpool Electric Bikes" "Blackshaws" "Bunneys Bikes" "Camden Cycles" "CJ Cycles" "Colour Supplies" "Cycle Sense" "Cycle Technology" "Cycle Wand" "Cycle Works Yorkshire" "Drayton Cycles" "Ebike Capital" "Ebike Electric Cycle Centres" "Ebikes Direct (MTF)" "Eco Bike Company" "Eden-e-motion" "Edwardes Camberwell" "Electric Bike Vault" "Electric Rider" "Espokes" "Geared Up Cycles" "Grizedale MTB" "Hereford Electric Bikes" "Hills Cycles" "Holcross" "Hopkinson Cycles" "Howards Cycles" "I Cycle" "JACS Electric Bikes" "Jobes Cycles" "Just Bikes Ashby" "Kings Cycles" "Langsett Cycles" "Leslie Bike Shop" "Mitchells Swindon" "Mitchells Gloucester" "Motosave Cage A" "Motorsavers Corby" "Newlec Cycles" "Northfield Cycles" "Off the Rock Cycles" "Pedal Electric Cycles" "Pentewan Valley" "Philip Lang Cycles" "Planet Bike" "Powerbikes" "Ride A Bike" "Ride It Cycles" "Rileys Cycles" "Romney Cycles" "Sax Velo" "Southport Electric Bikes" "Start Fitness" "Swinnerton Cycles" "The Bicycle Chain" "The Bike Cellar" "The Bike Shop Wales" "Top Gear" "Town Bikes" "Wallington Cycles” "Wilco Motor Spares" "Winstanleys Bikes"]

Frame Number: Your frame number is engraved into the frame under the bottom bracket. This is the part of the frame the pedal axle passes through

Bike Model:
[select* bike_model "Commute Ex Gents 19" "Commute Ex Gents 21" "Commute Ex Ladies 15" “Commute Ex Ladies 17" "Fold" "Fold LS" "Step NX 700" "Step NX 26" "Commute INT Gents 19" "Commute INT Gents 21" "Commute INT Ladies 15" "Commute INT Ladies 17" "Commute INT Unisex 15" "Commute INT Unisex 17" "Trail Destroyer 17" "Trail Destroyer 19" "Trail Destroyer II 17" "Trail Destroyer II 19" "Other"]

Proof of Purchase:

Brief description of the issue:

Photos of the issue: