Department of the…

                                            Department of the Secretary of State
                                                Bureau of Motor Vehicles

                                        MOTORCYCLE RIDER EDUCATION
                                          SITE/RANGE APPLICATION

                                                                                  _____ ____              _____
                                                                                   New    Renewal         Site #

Site Name:________________________________________

Mailing Address:_____________________________________________________________
                                               (RR #, PO Box or Street Address)

                                   (City)              (State)               (Zip Code)        (County)
Office Telephone #:______________________                 Website:

Contact Person: _________________________ Email:

Home Telephone #:_______________________                    Cell#:

Is this location already licensed for driver education use?
If yes, you do not need to resubmit city and fire approval.

                                  Indicate each classroom address and location:

1. ________________________Lic#______                  2. _______________________Lic#______

   ________________________________                     _______________________________


3. ________________________Lic#_______ 4. _______________________Lic#______

   ________________________________                     _______________________________


                    Indicate each range address and location (if different from classroom):

1. _______________________Lic#_______                  2. ________________________Lic#_____

   ________________________________                     _______________________________


3. _______________________Lic#_______                  4. ________________________Lic#_____

   ________________________________                     _______________________________


Do you currently have an MSF RERP number (for range sites only)? If yes, what is the number?
# __________



            Secretary of State, BMV, Driver/Rider Education, # 29 State House Station, Augusta, ME 04333-0029
Rev 11/05
What is the name, date of birth, motorcycle instructor license type and number of each instructor
employed by this motorcycle school?

    Name                           Date of Birth                     License Type and License Number




Requirements for initial application for site/range :

1. A letter or certificate of occupancy from municipal code enforcement officials as proof of compliance
   with land use ordinances.
2. A letter from municipal or state fire officials as proof of compliance with fire safety regulations.
3. Proof of liability insurance as required by MSF. Range only.

License fees:

1. A $50 fee for each classroom location.
2. A $50 fee for each range location.

I certify that the information contained herein is true and that any changes will be reported to
the Secretary of State, Bureau of Motor Vehicles within 30 days of the effective date of the change. I
agree any misstatement on this application shall be grounds for suspension, revocation, or denial of site
certification.

                                Signature                                Date

Make check or money order payable to Secretary of State or complete the credit card information below.

If you are paying by credit card and would like to fax your completed application to us, the fax
number is 624-9158.

I would like to pay my license fee by charging it to my:
q Visa
q Mastercard


The amount to be charged to my credit card is:
q $50.00 (each site/range) Total to be charged $


Credit Card Number                                                    Expiration Date
                                                                                              Month/Year
Your address that you receive your credit/debit card statement at:


Name as it appears on the credit card (please print)

Signature                                                         This transaction cannot be processed
without the cardholders signature.

Daytime telephone number of cardholder
            Secretary of State, BMV, Driver/Rider Education, # 29 State House Station, Augusta, ME 04333-0029
Rev 11/05