Your Mobility is Our Passion Campaign
Fill the form to apply for a free system (All requests will be considered carefully). Read the campaign rules here: https://bit.ly/2VW8zPd
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Email *
First and Last Name *
10-digit Mobile Phone Number *
House or Apartment Number *
Street *
City *
State *
Zip *
Country *
What kind of disability do you have? *
Please describe your disability in the letter to be submitted
Required
What is your annual income? *
What is your age? *
What is your sex? *
Do you own a tadpole recumbent trike? *
If you have a tadpole recumbent trike, what brand is it? *
Please specify the brand of your trike
Do you own a bike or a cargo bike? If so what type and brand is it? *
Please tell us your story. Describe your hardship and need (2-3 Paragraphs). *
A copy of your responses will be emailed to the address you provided.
Submit
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