Bike Registration Form

Bicycle Registration Form

To initiate the bicycle registration process:

bullet Print out this page.
bullet Complete the first five lines of information requested below – name, date of birth, address, and phone number. Please print legibly. The remainder of the form will be completed with the assistance of Purdue Police Department staff.
bullet Bring this sheet and your bicycle to the Purdue Police Department, 205 South Martin Jischke Drive. You must bring your bicycle with you.
Last Name ___________________________________________________________
First Name _______________________________________Middle Initial_______
Date of Birth ___________________________________________________________
Local Address __________________________________Phone_____________________
Home Address __________________________________Phone_____________________
   
Make of Bicycle ___________________________________________________________
Model ___________________________________________________________
Color ___________________________________________________________
Serial Number ___________________________________________________________
Miscellaneous Number ___________________________________________________________
For Police Department Use Only ___________________________________________________________
Tag Number Registered By ___________________________________________________________
Date Entered ___________________________________________________________