STATE OF CONNECTICUT
2020 RIDER EDUCATION PROGRAM REGISTRATION FORM
*This information will be shared with CT Department of Transportation
1) PLEASE PRINT CLEARLY:
Date of Birth:
City: State: Zip:
Phone # Home ( ) Work ( )
Sex: M or F
Driver's License #: State: _____ Exp. Date: / /
Motorcycle Permit #: State: _____ Exp. Date: / /
IMPORTANT: PLEASE BE SURE TO ENTER YOUR DRIVER’S LICENSE NUMBER
CLEARLY AND CORRECTLY. ANY ERROR WILL CAUSE A DELAY
IN PROCESSING YOUR MOTORCYCLE LICENSE.
2) THE INFORMATION IN THIS BOX IS REQUIRED ONLY FOR THOSE STUDENTS WHO HAVE
REQUESTED TO USE THEIR OWN SCOOTERS. Scooter students must have a motorcycle permit or
license in order to register, and the scooter is subject to a safety test by the instructor.
Is license endorsed for motorcycle?
Yes, endorsement date: / /
No (you MUST have a current learner’s permit to use a Scooter in BRC)
Insurance Company (not agent): Policy #:
Riding Experience: _______ years. Approximate Miles per year: ________________
3) PLEASE READ AND SIGN: I certify that the statements made by me on this registration form are
complete and true to the best of my knowledge and belief, and are made in good faith.
4) PLEASE NOTE: YOU MUST ALSO SIGN
THE ENCLOSED STATE OF CT WAIVER FORM
(Double-sided form: Adult/Minor)