FAX NUMBER
Have you ever attended/completed any of the following motorcycle training classes?
List any other educational institutions you attended or any specialized training you received. (Do not list motorcycle training or classes conducted by the
Virginia Rider Training Program.)
Have you ever had your driver license suspended or revoked? If yes, list below.
HIGH SCHOOL GRADUATE?
IF NO, DO YOU HAVE A GED?
MOBILE TELEPHONE NUMBER
PURPOSE: Use this form to apply to become a Virginia Motorcycle Rider Training Program Instructor/Rider Coach.
INSTRUCTIONS: Type or print in ink to complete the application, sign and return it to the Virginia Motorcycle Rider
Training Program at the above address.
VIRGINIA RIDER TRAINING PROGRAM
INSTRUCTOR/RIDER COACH APPLICATION
TSS 98 (02/18/2020)
FULL LEGAL NAME (last) (first)
(middle)
(suffix)
ADDRESS CITY ZIPSTATE
ARE YOU OVER AGE 18?
YES
GENDER
MALE FEMALE
YES
COLLEGE / UNIVERSITY GRADUATE?
NO YES NO
Do you currently ride a motorcycle?
YES NO
BASIC RIDER COURSE EXPERIENCED RIDER COURSE SIDECAR/TRIKE COURSE
YES NO YES YES NO
HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER
EMAIL ADDRESS BIRTHDATE (mm/dd/yyyy)
DRIVER LICENSE NUMBER OCCUPATION
What type of motorcycle do you own?
How many years have you had your "M" classification?
How many years have you been a motorcyclist?
List other motorcycle training classes you have attended/completed.
YES
NO IF YES, INDICATE MAJOR:
YES
LOCATION (city/county, state)
IF YES, DATE (mm/dd/yyyy):
APPLICANT INFORMATION
MOTORCYCLE EXPERIENCE
NO
NO
NO
IF YES, DATE (mm/dd/yyyy): IF YES, DATE (mm/dd/yyyy):
DATES: FROM (mm/dd/yyyy) TO (mm/dd/yyyy)INSTITUTION / TRAINING
REASON DATE (mm/dd/yyyy)
CLASS NAME DATE (mm/dd/yyyy)
