Hybrid and Road Bike Request Form Cyclist #1 add Name (required) Please provide a valid Name Height Height 137cm-4'6" 140cm-4'7" 142cm-4'8" 145cm-4'9" 147cm-4'10" 150cm-4'11" 152cm-5'0" 155cm-5'1" 158cm-5'2" 160cm-5'3" 163cm-5'4" 165cm-5'5" 168cm-5'6" 170cm-5'7" 173cm-5'8" 175cm-5'9" 178cm-5'10" 180cm-5'11" 183cm-6'0" 185cm-6'1" 188cm-6'2" 191cm-6'3" 193cm-6'4" 196cm-6'5" 198cm-6'6" 201cm-6'7" 203cm-6'8" 206cm-6'9" 208cm-6'10" Inseam Inseam 51cm-20" 53cm-21" 56cm-22" 58cm-23" 61cm-24" 64cm-25" 66cm-26" 69cm-27" 71cm-28" 74cm-29" 76cm-30" 79cm-31" 81cm-32" 84cm-33" 86cm-34" 89cm-35" 91cm-36" 94cm-37" 97cm-38" 99cm-39" 102cm-40" Bicycle Bicycle Specialized Globe Comp Specialized Crosstrail Specialized Sirrus Comp Specialized Vita Scott Speedster Accessories Handlebar Bag Rear Rack Bag Padlock Luggage storage Panniers Set Burley D Lite Trailer Trail a bike Bub Luggage trailer Personal Info Email (required) Please provide an Email Please provide a valid Email Bicycle Pick-up / Drop-off CicloCuba´s Hours of Operation Monday to Friday: 9:00 am to 5:00 pm Saturdays by advance appointment only Click on calendar and select preferred Date / Hour / for pickup/dropoff Note: 3-day minimum requirement for advance reservations. Walk-ins are welcome and will be assigned equipment from remaining inventory. Cash deposits are required for walk-in rental clients. Pick-up Date (required) today Drop-off Date (required) today Days 0 Pick-up / Drop-off Location San Pedro # 258, between Sol & Muralla, Old Havana Rental Info Total Deposit $0.00 USD Total $0.00 USD Payment Information A $75 USD deposit (equivalent to $81.11 USD paying by Visa or MasterCard) is required per bicycle, to be processed upon confirmation of equipment availability. Third party credit cards are not accepted. Presentation of the card is required locally in Cuba upon opening rental contract. The Canadian credit card processer to appear on your credit card statement is MacQueen's Tours. Cardholder (required) Please provide a valid Cardholder Card Number (required, no spaces/no dashes) Please provide a valid Card Number Please provide a valid Credit Card Pattern Card Expiration Date (required) today Please provide a valid Card Expiration Date 3-digit security code (this # is normally found on the reverse of the card ) Please provide a valid Security Code Invalid Security Code length Invalid Security Code length Billing address Address City Province/State Postal Code Country Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadaloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldava Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Phillipines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Notes, Comments or Other Services Required Reservations cannot be processed without completed form. I have read, understand & agree to the conditions of CicloCuba's Rental Terms & Conditions. CicloCuba assumes no responsibility, however caused, for injury, loss or damage to person or property in connection with any service resulting directly from the following: acts of God, detention, annoyance, terrorism, thefts, pilferage, civil disturbances, government restrictions or regulations, strikes, delays and expenses arising from quarantine, failure of any means of conveyance to arrive or depart as scheduled, discrepancies or change in transit or accommodation services over which we have no control or other financial loss whether to persons or property arising out of certain risks and danger which may occur during your holiday, including but not limited to the hazards of activities in general. Our contract is for rental only and not for sale of equipment. The renter agrees that he/she will rent the items(s) herein requested and that they will at all times remain the property of the rental agent named in the rental contract, that he/she will examine the said item(s) upon delivery, and return them in the same condition as when rented, by the stipulated date/time of return, that he/she will pay all charges for said item promptly when due, and that in the event equipment is stolen or damaged, the renter named in the rental contract will be responsible for its retail replacement value, and the rental agent is hereby released from all claims arising therefrom. All charges are based on the time the item is in the renter’s possession whether in use or not. The rental agent is not responsible for accidents or injuries caused directly or indirectly in the use of the rented item. There are items that require your attention. Please check and submit your request. Submit