1. Name _________________________________________________
(You must be over 18 years of age at the time of a RiderCoach Preparation Workshop (RCP).

Address ________________________________________________________________

City _________________________________ State________ Zip ______________

E-mail ____________________________ Home Phone (_____)_________________

2. Employer ____________________________________ Work Phone (____)_____________

Rank or Title ___________________________ Years with Employer ___________

• OK to contact employer for reference? Yes No

3. High School or Tech School and Graduation Date

_______________________________________________________________________

4. Undergraduate College/University, Degree, and Graduation Date

_______________________________________________________________________

5. Graduate and/or Doctorate-level College/University, Degree, and Graduation Date

_______________________________________________________________________

6. Specialized Training or Teaching Experience (Please identify any certificates or degrees received and dates; indicate what you taught, where, and when.)

_______________________________________________________________________

7. Driver License # _____________________________________ State _____________

(Please attach photocopy of license.)

• What year did you obtain a motorcycle license or endorsement? __________

(You must have held a motorcycle endorsement/license for at least Two years prior to an RCP.)

• Ever had a motor vehicle license revoked or suspended? Yes No

• If yes, where and when? __________________________________________________

(You must not have had a license suspension or revocation or received more than two moving violations in the last two years, or been convicted of a DUI offense in the last 5 years.)

8. What type of motorcycle(s) do you own? (You must have owned a motorcycle for at least two years prior to the RCP.)

_____________________________________________________________________________

9. Do you belong to any motorcycle clubs or organizations?

____________________________

10. What type of riding do you do now or have you done in the past?

Dirt ___ Touring ___ Commuting ___ Other: _________________

• Type of competitive motorcycle racing you currently do or have done in the past?

Enduro ___ Flat Track ___ Moto-cross ___ Road Racing ___ Trail ___ Trials ____

11. Which site is your sponsor? ______________________________________________

12. What was the date and location that you took the Basic Rider Course? (Must be within 1 year of the RCP)

Date ___________________ Site ______________________________________

• Have you completed an MSF-approved Experienced Rider Course? Yes No

(Please attach a copy(s) of your MSF course completion card(s).)

On a separate sheet of paper, please complete questions 13 -15. Please remember that the minimum requirements are to Shadow the full Classroom and Range two (2) times and work as a Range Aid three (3) times.

13. Please list all of the dates, locations and the name(s) of the RiderCoach(s) that you shadowed with in the classroom?

14. Please list all of the dates, locations and the name(s) of the RiderCoach(s) that you shadowed on the Range?

15. Please list all of the dates and locations that you Range Aided?

16. Describe on a separate sheet of paper why you want to become an MSF-certified Instructor for the MREP and attach it to this application.

17. If we accept you as an RiderCoach Candidate for an RCP sponsored by the MREP, briefly explain below how any of the following limitations might impact you.

Personal or work schedule limitations:

_________________________________________

Travel limitations _________________________________________________________

Other limitations _________________________________________________________

By signing below, I indicate my acceptance of the following:

1. I certify that the above information is complete and true to the best of my knowledge.

I am aware of and accept all requirements for an RCP sponsored by the MREP.

I understand that the RiderCoach Trainers may dismiss a RiderCoach Candidate who is unable to keep pace with the course or who poses a hazard to themselves or others from an RCP.

2. This application does not guarantee me a place in this or any RCP sponsored by the MREP. Even if I successfully complete an RCP, I do not have any guarantee of employment with the MREP or any private contractor associated with the MREP.

3. That my final acceptance into an RCP is contingent upon a satisfactory personal interview with the MREP's program manager and/or an MREP representative;

4. The MREP has my authorization to verify my current employment status, my current and future Massachusetts driver's record, and to check for any outstanding warrants with any Federal or State law enforcement agencies.

Signature _________________________________________ Date ________________