Registration Form

Registration Form

This registration is for (check only one): Amount Enclosed: $__________

____Basic Riding Course ____Intermediate Rider Course ____Experienced Rider Course

Please Print Clearly ____Trike Rider Course

Last Name________________________________________ Choice 1-Course#__________

First Name______________________________ M.I._______ Choice 2-Course#__________

Address__________________________________________ Choice 3-Course#__________

City____________________________________ State_____ Choice 4-Course#__________

Zip + 4 ________________-_________ Choice 5-Course#__________

Home Phone ( ______ ) ________________ Choice 6-Course#__________

Work Phone ( ______ ) ________________ If all of your choices are full, which

E-mail _______________________________ of the following would you prefer?

Date of Birth (MM-DD-YY) __________________ Sex (M/F) ____ ___ Standby List

Drivers License# __________-__________-__________ State____ ___ Next Available Class

Drivers License Classification (check all that apply) ___ Do Not Register; Return Fee

__A __B __C __D __L __M __CDL __Non-Illinois License

Duplicate this form if you need more copies

Send to: Motorcycle Rider Program

Safety Center

Mailcode 6731

Southern Illinois University

Carbondale, IL 62901