Name:_______________________________

E-Mail:_______________________________

Phone Number:(_____)__________________

Alt. Phone Number:(_____)______________

Fax Number:(_____)____________________

Recipient Name:_______________________

Shipping address:______________________

City:______________State:___Zip:________

Address Continued:_____________________

Receive, build, re-box and ship

$125.00 Plus actual freight charge

Receive, build, Tune-up, re-box and ship $185.00 Plus parts, Plus actual freight charge.

Please contact me before exceeding

$________________ in parts.

Note:If this line is left blank we will install, and charge for, up to $30 in parts.

Please insure bike and contents for $______

Note: Cost of shipping will be actual UPS shipping charge. Expect return shipping charge to by similar to charge for shipping it to us. You may be able to save on freight by using the carrier's website to arrange return freight, then printing the return shipping label and providing it to us.

I will provide my return shipping label

Credit Card Number:_________________________________________________________

Expiration Date:___________

Billing Zip Code:___________

We accept:

Visa, MasterCard, or American Express

V-code:________

Today's Date:___________

Manufacturer of bike:____________________

Model of bike:_________________________

I understand that there is an inherent risk associated with shipping a bicycle. I release Bicycle World of Louisiana from any claims regarding the loss, damage, and/or delay of my bicycle.

Name____________________________  Signature________________________________

Please print this form, fill it out  and fax it to 504-838-6848