NH Department of Safety
Division of Motor Vehicles
Motorcycle Rider Training Program

2011 Course Registration Form


























Student Information
Please print clearly in ink:

________________________________________________
Last
Name
First
Name
M.I.
________________________________________________
Mailing Address
________________________________________________
City/Town
State

Zip
________________________________________________
Evening
Phone
Daytime
Phone
________________________________________________
Date of Birth


Driver License Number
________________________________________________
E-mail Address (optional)
We will notify you of your class assignment by mail, so provide
a current mailing address. If a class is re-scheduled, we will
notify you by telephone so list a day and evening telephone
number where we can contact you. If you are under the age of
18, you must have a parent or guardian co-sign your registration
form.
Course Type and Fees
Choose one of the following:
____
Basic Rider Course (BRC) $110.00
____
Intermediate Rider Course (IRC) $50.00
Requires previous attendance

in a Basic level class. Previous class # __________
____
Experienced Rider Course (ERC) $60.00
Course Selection
When are you available to take the course? List as
many dates as possible. Next to the dates, list your
preferred locations in order of your preference.
Code Dates
Locations




































Please note: Classes fill very quickly, especially at the
beginning of the year. By choosing many different dates
and locations, you increase your chances of being
enrolled in a class. Add an additional sheet if necessary.
If all of your choices are full, we will return your
registration and request that you add more dates.
Student Background
How much recent bicycle riding experience do you have?


None



A Little



A lot
Describe your previous motorcycling experience.

None

Passenger Only

Some Street Riding

Dirt Bike Only

More than 2 years riding

Other ___________________________

Do you currently own a motorcycle?



No



Yes
Do you currently hold one of the following:

NH Motorcycle Permit?
 

No



Yes
___________


For how long?


NH Motorcycle License?


No



Yes
___________






For how long?

How did you hear about this course? __________________

In what NH County do you live? Please circle one:
Belknap Carroll Cheshire Coos Grafton
Hillsborough Merrimack Rockingham Strafford Sullivan
Please read the following and sign below: Participation in this course does not guarantee receiving a motorcycle
endorsement. Successful completion of the course requires full attendance at every session and the successful completion
of both a written test and a riding skill evaluation. If you are unable to complete the course or do not pass the evaluations,
you will not receive a waiver of the DMV skills test. During the course, if you are unable to meet the objectives of the training
or if you put yourself or any other student at risk, the Instructor must dismiss you from the course. This course is
non-transferable. If you were not able to attend your scheduled course and would like to request a refund please see the
requirements necessary per Saf-C 5305.04
Signature: ____________________________________________ Date: ______________________

Parent/Guardian Signature: ______________________________ Date: ______________________

(For applicants under 18 years old)
DSMV 414 (Rev. 01/11)

Mail Completed Registration Form & Payment to:



NH DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
ATTN: MOTORCYCLE RIDER PROGRAM
23 HAZEN DRIVE
CONCORD, NH 03305


Select Payment Option

Check or Money Order. Please make payable to "NH DMV"
Returned check policy:
We may re-present your checks electronically for any check returned for insufficient or uncollected funds. Your returned check will not be
provided to you with your bank statement, but you can get a copy by contacting your financial institution. Per RSA 6:11-a, A fee of $25 or 5
percent of the face amount of the check, whichever is greater, plus bank fees, will be charged for each returned check and collected with a
separate electronic transaction.

Credit card. Please provide your credit card information below:


Card Number: __________________________ Exp. Date:

Name of Card Holder:

Billing Address:




Card Holder’s Signature: ____________________________________

Type of card


Visa

Master Card

American Express

For Office Use Only
__________________________________________________________________________________________