This form may be completed electronically. Place your cursor in the "Date" box, type the date and then tab to the next box. Complete this application, print it, and mail to the course site you select below. Date

Name (as on your Driver's License) M F Date of Birth

Address City State
Zip E-Mail Address

Telephone (home) (work) (cell)

Social Security Number Driver's License No. State Type
(SSN - Mandatory State Licensing Requirement)

Can you ride a bicycle? Have you ridden a motorcycle? Driver Passenger

Do you have any disabilities or take medications that may affect your physical performance? Please explain.


Motorcycle insurance company and policy number (required for Experienced RiderCourseŽ only)

Sites operate independently and registration forms are not transferable between them. Choose a RiderCourse:

Choose your Course Site:

Class Date: 1st Choice 2nd Choice

Visa/Mastercard Expires

Signature ___________________________________________________________________________

Mail completed application and check, money order, or credit card information
to the site you selected, as listed below. PLEASE DO NOT SEND CASH. Karns High School - make check payable to Knoxville Rider Education Program (KREP)
Mail to: KREP, P.O. Box 5582, Knoxville, TN 37928
Phone: 865-687-2986 Fax: 865-687-1884

Pellissippi State Technical Community College (PSTCC) - make check payable to PSTCC
Mail to: PSTCC, Attn: Angela Branson, 10915 Hardin Valley Rd, Knoxville, TN 37933
Phone:865-539-7166 or 865-539-7167 Fax: 865-694-6583

Walters State Community College (WSCC) - make check payable to WSCC
Mail to: WSCC, Attn: Allison Carmichael, 500 S. Davy Crockett Parkway, Morristown, TN 37813
Phone: 423-585-6843 Fax: 423-318-2328

PLEASE SIGN THIS APPLICATION