RiderCoach Application Form

Please complete this application as much as possible. The red asterisk indicates a required field.

  Personal Information  

First Name  *

  

Last Name  *

  

Enter your email address:  *

 Your email address must be valid

Gender 

Male
Female
  

Date of Birth  *

 Please enter only numbers (month,day,year)

Social Security Number 

  To protect your security and privacy the Educational Program Manager will contact you directly for this information.

Resident Address  *

  

City  *

  

State/Province  *

  

Zip Code  *

 Please enter 5 numbers

Mailing Address 

Please complete this field if your mailing address is different from your residence address

Employer  *

  

Occupation 

 

Home Number  *

  

Work Number  *

  

Cell Number 

 

Pager Number 

 

Fax Number 

 
  Within the last 10 years, have you been convicted of a crime or felony involving violence, dishonesty, degeneracy, moral turpitude, including but not limited to theft, forgery, making false written statements, rape, perjury, fraud, or bribery? Please indicate this with a "Yes" or "No" response below.   

Convictions 

 
  Site Sponsorship You must have site sponsorship. If you have not contacted a site administrator for sponsorship, please do so before completing the rest of this form. You can email me and I will inform you of the training site in your area.

Training Site Sponsor  *

  

Tuition Aid 

All
Some
None
 Please indicate here if your site sponsor will provide any financial assistance for the course tuition.
  Driver License Information Please note that New York State Department of Motor Vehicles Part 138, 138.7(b)(3) requirements for RiderCoaches are as follows: "A RiderCoach of a motor vehicle accident prevention course must have no driver's license suspension or revocation within the five (5) years prior to becoming a RiderCoach (with the exception of an indefinite suspension which can be terminated by the performance of an act by the licensee) and no alcohol related driving conviction within seven (7) years prior to becoming a RiderCoach."

Driver License Number  

   To protect your security and privacy the Educational Program Manager will contact you directly for this information.

State Issued 

 

Date Issued 

 

Date Expires 

 

Suspension or revocation 

Yes
No
  

If yes, describe the suspension 

 

Date Reinstated 

 
  Emergency Information  

Medical 

If you have any medical condition or special needs that we should be aware of, please list them here.

Emergency Contact Name 

Please enter contact person's full name

Emergency Contact Phone Number 

 

Relationship 

 
  Education Information  

Highest Level of Education 

GED
High School
College
 This information is required by New York State DMV regulations.

Address of High School 

 

Address of College 

 

College Degree 

 

College Major 

 

List any other educational institutions you have attended 

You can also list here any specialized training you have received. Please be sure to identify any certificates or advance degrees.
  Motorcycling and educational Experience  

Do you currently ride 

Please enter yes or no

Types of motorcycles you own 

 

Years that you have had a motorcycle endorsement 

 

Type of Riding 

Dirt
Touring
Street
Other
  

Competitive racing 

If you have participated in any competitive racing, indicate this with a yes or no response.

Are you familiar with any of these motorcycle safety courses 

 

Have you attended or completed any of the following courses 

 

If attended, please give date 

If you have attended any of the described motorcycle safety courses, please indicate the dates of completion. You can also describe any other courses that might not be listed above.

Currently teach rider education 

Indicate with a yes or no if you teach any rider education course, MANYS approved or not.

If yes, please list the name of the sponsor 

 

Course location 

 

Number of courses taught 

 

Teaching experience 

Give a brief description of any teaching experience you might have such as scuba instructor, swim instructor, professor, technical college instructor, public school system teacher, etc.

Why do you want to do this 

Describe, in as much detail as possible, why you want to become an MSF and MANYS certified RiderCoach in the state of New York.
  Statement of acknowledgement and consent  

Statement of Consent  *

 I understand
 I understand that this application does not guarantee me a position in a RiderCoach Preparation Course. I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I also understand that if the Motorcycle Safety Foundation (MSF) or the Motorcycle Association of New York State, Inc. (MANYS) finds that a material false statement or misrepresentation of the facts called for in this application has been made, I may be cited for a hearing from MANYS. The findings of this hearing will be forwarded to MSF and may result in the revocation of my RiderCoach certification from MANYS, MSF, or both.

Upon submission of this application, I am authorizing MSF and/or MANYS to check on any and all facts contained herein to include but not limited to a Department of Motor Vehicle license and safety history background check. In addition, I hereby release MSF and/or MANYS and any of their employees or agents from any and all liability for damages of any nature arising from obtaining or attempting to obtain the requested information.

Release of Information  *

 I consent
 By submitting this application, I authorize the New York State Department of Motor Vehicles to disclose or otherwise make available to the Motorcycle Association of New York State, Inc. personal information about me obtained by the Department in connection with a motor vehicle record.