MTA 2W RiderCoach Application

First Name: *

Middle

Last Name: *

Address: *

City: *

State: *

Zip: *

Are you 21 years of age or older? *

Yes
No

Employer:

Occupation *

Home Phone:

Work Phone

Cell Phone: *

E-mail Address: *

Sex *

Male
Female

Driver's License Number: *

State Issued from: *

During the last three (3) years have you received more than 8 points on your license? *

Yes
No

Has your driver's license been revoked or suspended within the previous three (3) years? *

Yes
No

High School or GED? *

Yes
No

College/University Graduate? *

Yes
No

List other primary educational institutions you attended or any specialized training you have received. Note non-motorcycle related certifications and/or degrees.

Give a brief description of any teaching experience.

Position Applying For: *

How many classes do you think you may coach in a year? (Minimum of 3 to keep your Colorado MOST certification) *

2-4
5-7
8-10
11+

How many years have you been operating a motorcycle? *

How many years have you had a motorcycle endorsement? *

What type of motorcycle(s) do you currently own? *

How many miles did you ride last year?

What type of riding do you currently do? *

Touring
Commuting
Off-Road
Day Trips
Other

Have you completed a BRC as a student within the last year? *

Yes
No

If so, when?

If so, where?

Military, If Active Duty check the following:

Rank

Shirt Size: *

Are you already an MSF certified RiderCoach? *

If yes, what is your MSF RiderCoach ID?

Describe in detail, why you want to become a certified motorcycle safety instructor and work for MTA: *

Give a brief description of any public speaking presentations you have done.

Are you being recommended by a RiderCoach? *

Yes
No

if yes, then please state who:

This application does not guarantee a position in a RiderCoach Preparation Course nor does it guarantee the Motorcycle Safety Foundation (MSF) will grant certification or that Motorcycle Training Academy will grant a position upon successful graduation. If the applicant successfully completes the RCP, the MSF may issue appropriate certification. Unless and until the MSF issues certification, the applicant is not a certified RiderCoach for the BRC and may not make any representations or perform any acts as such. *

Agree
Disagree

I certify that I have read this RiderCourse RiderCoach Preparation Candidate Application in its entirety, and the information contained herein is true and correct and that I have not omitted any relevant information. I understand and agree that falsification of any information herein, or the omission of any relevant information, will result in immediate revocation of my MSF RiderCoach Certification. *

Agree
Disagree

I acknowledge that the following will be sent with this application: *

A fully completed and signed RCP application.
A recent (within 30 days) Colorado Driving Record, if less than 3 years in Colorado, then an out of State Driving Record is required.
Vendor and RCP candidate Training Agreement

I acknowledge that prior to the first day of the RCP the following items will be turned in: *

Current First Aid/CPR certification proof of completion
BRC Completion Card completed within a year of RCP
BRC Apprenticeship Attestation Form
Completion certificate from the MSF Basic eCourse

I acknowledge that prior to the first day of the RCP I will: *

Review the MSF RC/T Rules of Professional Conduct.
Complete the RCP PreCourse assignments.

I acknowledge that: *

I agree to return all course related materials if unsuccessful in the RCP.
There is a 6-month period before re-application wo an RCP is accepted.

Signature (Type full name if you agree to all) *

* Required