RiderCoach Application

RiderCoach Application
RiderCoach Application
Become a RiderCoach

INSTRUCTIONS:
1. Complete application
2. Return completed application by selecting "SUBMIT"
Full Name:*
(last, first, middle initial)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Drivers License Number*
Email*
example@example.com
Occupation*
Education, degrees, fields of study, specialized training and/or certifications:
Affiliations/memberships in any motorcycle, social, community, fraternal or other groups, clubs, organizations:
Riding Experience

If you are not an Indiana resident, or hold a driver’s license from another state, you will need to supply a copy of your official driving record with this application.
How many years have you held a valid motorcycle license endorsement?*
How many years have you operated a motorcycle? *
Average annual miles riding a motorcycle:*
Do you currently own and operate a motorcycle?*
If yes, provide the following information.
Make:   Make*
Model:   Model*
Year:   Number*
Odometer Reading:   Number*
Make: Make
Model:Model
Year: Number
Odometer Reading: Number
Have your driving privileges been suspended in the past seven (7) years?*
If yes, please explain and state current license status.
Have your ever been convicted of any crime?*
If yes, please explain:
Have you ever participated in a motorcycle rider education course?*
If yes, provide the following information:
Course Type:   Course Type
Year:   Number
Location :  Location
Instructor's name:   Name
Course Type:   Course Type
Year:   Number
Location:   Location
Instructor's name:   Name
Are you willing to conduct at least three (3) classes per year upon successful completion of the instructor/coach prep workshop?*
We ask that you be willing to Range Aide for at least on weekend prior to being placed on an upcoming RiderCoach Prep list. This will help you understand the requirements and processed needed to become a RiderCoach.*
If you are an active MSF RiderCoach; provide RiderCoach Number
if you are from another state please email a copy of your driving record to coaches@riders-frist.com.
Signature*

Clear
Date*

MonthDayYear
Date
Location(s) you wish to work: (Select all that apply)*

AndersonBargersville/GreenwoodClarksvilleFort WayneIndianapolisLafayetteMichigan CityPlainfieldRichmondSchererville
Sponsor Name:*
Should be Empty:

RiderCoach Application

Riding Experience

If yes, provide the following information.

If yes, provide the following information: