| Date of Application | Phone |
| Name | City |
| Street Address | Postal Code |
| Unit or apartment | Province |
| How did you hear about this Display? | |
| Bike #1 | (please provide as much information as possible as this will give us the material for making up the bike signage) | |
| Year | Make | Model |
| Country of Origin | Original or Restored | |
| Are you the Owner? If not, owner's name: | Road Bike or Competition | |
| Description: | ||
| . | ||
| . | ||
| . | ||
| Special Features: | ||
| . | ||
| . | ||
| . | ||
| Bike #2 | (please provide as much information as possible as this will give us the material for making up the bike signage) | |
| Year | Make | Model |
| Country of Origin | Original or Restored | |
| Are you the Owner? If not, owner's name: | Road Bike or Competition | |
| Description: | ||
| . | ||
| . | ||
| . | ||
| Special Features: | ||
| . | ||
| . | ||
| . | ||