Bicycle Registration Form

Department of Police Services

Registration #:

Bicycle Registration Form

I. PERSONAL INFORMATION:

First Name:		Last Name:		Email Address:


Driver license:		Student ID:


Mailing Address:
Street:			P.O. Box:
City:			Phone:
Zip Code:			2nd Phone:

Home Address (If different from Mailing Address):
Street:			P.O. Box:
City:			Phone:
Zip Code:			2nd Phone:

II. BICYCLE INFORMATION:
Make:	Model:		Men's:	Women's:	Color:


Bicycle Serial Number:			Click Here for Bicycle Serial Number Locations!
					Speeds:
Other Identifying Marks:

Date Purchased:		Value When Purchased:


(1) Fill in
(2) Print out
(3) Sign this form below.
(4) Print form and deliver in person with your bicycle to:

Department of Police Services, Crime Prevention Unit (818) 677-5820 Darby Avenue and Prairie Street
(You must complete this process for your registration to be complete!)

I CERTIFY THAT THE BICYCLE I AM REGISTERING BELONGS TO ME AND WAS OBTAINED LEGALLY.I WILL PROVIDE SUCH PROOF UPON REQUEST. I UNDERSTAND THAT REGISTERING MY BICYCLE THROUGH THE UNIVERSITY'S BICYCLE REGISTRATION PROGRAM IS NOT A GUARANTEE THAT MY BICYCLE WILL BE PROTECTED FROM THEFT OR LOSS. INSTEAD, THE PURPOSE FOR REGISTERING MY BICYCLE IS THAT THE INFORMATION I SUPPLY ON THIS FORM MAY BE USED TO CONTACT ME IN THE EVENT THE UNIVERSITY RECOVERS MY BICYCLE AFTER A THEFT OR LOSS. THIS REGISTRATION WILL REMAIN IN EFFECT THROUGH THE END OF THE NEXT ACADEMIC YEAR AND I AM RESPONSIBLE FOR PROVIDING UPDATED CONTACT INFORMATION SHOULD ANY OF THE ABOVE INFORMATION CHANGE.

*Signature:* _______________________________________					*Date:* ___________