Rider's Edge® Skilled Rider Course Registration

First Name: M.I. Last Name

Address:

City: State: Zip code:

Home phone: Work phone:

Email:

Date of birth m/d/y : Gender: Male Female

Height: feet inches

Drivers license #: State:
Expiration Date m/d/y:

 Learner’s permit: Yes No
Expiration Date:

Motorcycle Registration? Yes No
Motorcycle Owner? Yes No
Proof of Insurance? Yes No

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What make of motorcycle do you ride?
Harley-Davidson^® Buell^®  Other None

What size motorcycle do you ride? cc Comments:

What is your reason for taking this course?
I take it periodically Obtain a license I haven’t ridden in a while Other

Have you taken a beginner motorcycle safety course before? Yes No
If yes, which course did you take?
Rider’s Edge^® New Rider Course
State Operated Course Other/Other Private entity

Describe your motorcycle experience?

It’s been more than 5 years since I’ve ridden a street motorcycle

I have less than 1 year riding experience on a street motorcycle

I have between 1 - 4 years riding experience on a street motorcycle

I have between 5 - 9 years riding experience on a street motorcycle

I have between 10 - 14 years riding experience on a street motorcycle
I have 15 or more years of riding experience on a street motorcycle
 

How many miles do you typically ride in a year?

Less than 3,000 miles per year 10,000 - 20,000 miles per year
3,000 - 5,000 miles per year More than 20,000 miles per year
5,000 - 10,000 miles per year

How did you hear about this course?

Flyer Special Event/Promotion Radio Dealership Friend/Family

Internet Magazine Newspaper Other – Specify:

Do you wish to be contacted by direct marketing? Yes No