MREP RiderCoach Candidate ApplicationMREP RiderCoach Candidate Application
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
_______________________________________________________________________
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 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
a 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 working 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 a MSF-certified Instructor for the MREP and
attach it to this application.
17. If we accept you
as a 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 unable to keep pace with the course or
who pose 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 interview with the MREP's program manager and/or a MREP representative;
4. The MREP has my
authorization to verify my current employment status, my current and future
Signature _________________________________________Date _________________