California Motorcyclist Safety Program Student Registration Form

ADVERTISEMENT

California Motorcyclist Safety Program
Student Registration Form
Site Name: ____________________________________________________________
Date _________________________
NCMT, Inc.
Personal Data
NAME: _____________________________________________________________________________________________________
First
Middle
Last
ADDRESS: __________________________________________________________________________________________________
Street
City
State
Zip
DOB MM/DD/YY _____________________ AGE ______ SEX r M
r F
WORK PH _____________________________ HOME PH ________________________ MOBILE ____________________________
EMAIL ___________________________________________________
Acceptable Government Issued Photo ID:
r State Driver’s License r Permit # ________________________ State: __________
Expiration Date: _______________
r State Identifcation # ____________________________________ State: __________
Expiration Date: _______________
r Foreign Driver’s License # _________________________ Country: ____________________ Expiration Date: _______________
r Passport # ______________________________ Country: ___________________________ Expiration Date: _______________
Verified Government Issued Photo ID By: ______________
(initial)
ON-STREET RIDING EXPERIENCE
1. Have you ridden a street motorcycle regularly in the last five years? r Yes r No
2. How much street riding experience do you have? (check one)
r Less than 500 miles
r 500 to 2000 miles
r More than 2000 miles
3. How long have you been riding? _______ years
4. Have you ridden off road? r Yes r No
5. How many on-street miles have you ridden in the past year? ______________ miles
6. Do you own a street motorcycle/motorscooter? 1. r yes 2. r no If yes, what size? ________cc
7. What is your primary reason for riding a motorcycle/motorscooter on street?
r Commuting r Recreation r Other _____________________________
8. Have you ever been involved in an on-street motorcycle/motorscooter accident? r yes r no
9. How did you hear about this course? (Check all that apply)
r Friend
r Tradeshow
r Catalog
r School
r Online Search
r DMV
r Dealer
r Insurance
r Courts
r Magazine
r CMSP website
r Brochure
r Other explain_______________________
10. Did you call for Motorcyclist Training Course information? r Yes r No
11. Have you ever taken this course before? r Yes r No
12. May CMSP contact you in the future? r Yes r No
___________________________________________________________________________________________________________
do not write below this line
office copy
written test score __________ riding test score _____________ DL 389 Cert. no: _______________
check one: r passed r failed r dropped early r dropped late r did not finish
If student is a carry over from a previous class, check this box r
Rev 3/15

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go