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Name

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Address

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Garaged Address (if different from above)
Email

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Phone

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Date of Birth

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Do you have a Motorcycle Endorsement?

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Yes No
Have you completed a Motorcycle Safety Course?

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Yes No
Date Completed (if yes to above)
Have you received any Traffic Violations in the last 3 years?

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Yes No
Have you been convicted of a DUI (driving under the influence) in the last 10 years?

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Yes No