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 ( )
Print Name:
Address:
Sex: M or F
Driver's License #: State: _____ Exp. Date: / /
Motorcycle Permit #: State: _____ Exp. Date: / /
(If applicable)
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.
Signature: Date:
4) PLEASE NOTE: YOU MUST ALSO SIGN
THE ENCLOSED STATE OF CT WAIVER FORM
(Double-sided form: Adult/Minor)
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