Course Number *Office use only                                              Application #

Today's Date

1st date/course choice                                 

2nd date/course choice

First Name                                            MI          Last Name

Address                                                                                           Apt #

City                                                       State                       Zip

Home Phone                                   

 Work Phone

Email Address

Date of Birth                         Gender     Male    Female            Height

Driver's License #                                

State

Expiration Date

Learner's Permit   Yes   No                                  

Expiration Date

Motorcycle Endorsement     Yes   No                  

Motorcycle Owner     Yes    No

What is your motorcycle riding experience?  Circle One: Never, Passenger only, Off-road motorcycle only, Street motorcycle

If you have ridden a street motorcycle, which level of street experience do you have?  Circle One:                 More than 6 months or 3,000 miles, less than 3,000 miles, less than 6 months, more than 5 years

Have you ever taken a beginner safety course before?     Yes    No

If yes, which one?

How did you hear about us?

Method of payment?     Cashier's Check    Check    Visa    MC   

 CC#_______-______-______-______ 3 digit code (in signature block)_____ 

Expiration Date ___/___/___  if paying by CC, you can fax to 414-486-7744