MREP RiderCoach Candidate Application

1. Name _________________________________________________

(You must be over 18 years of age at the time of an IPW.)

Address _______________________________________________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 photo-copy 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 IPW.)

• 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 IPW.)

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

10. What type of riding do you do now or have 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. Have you completed a Motorcycle Safety Foundation-approved (MSF) Basic RiderCourse (BRC)? yes no

• Have you completed a MSF-approved Experienced Rider Course?   yes    no

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

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

13. If we accept you for training as a RiderCoach candidate, 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 the training program sponsored by the MREP.

I understand that a RiderCoach Candidate unable to keep pace with the course or who pose a hazard to themselves or others may be dismissed from program by the RiderCoach trainer.

2. This application does not guarantee me a place in this or any RiderCoach training sponsored by the MREP. Even if I successfully complete the training, 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 a training program is contingent upon:

• a satisfactory personal interview with the MREP's program manager and/or a MREP representative;

• passing a riding skills evaluation conducted by a MREP-approved trainer by accumulating no more than 8 points on a single evaluation and no more than 15 points overall (only two chances will be given to pass the evaluation for any training program);

• payment of the current non-refundable training program tuition charge.

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 ________________