Attachment D - Training Provider Application.pdf

2/24/2022

COMMONWEALTH OF KENTUCKY

MOTORCYCLE SAFETY EDUCATION PROGRAM

Approval Process for Training Provider

ALL APPLICATIONS MUST INCLUDE THE FOLLOWING:

Please attach all required information in the order shown below.

1. Documentation of Qualifications

Description of expertise in offering this or similar types of programs.

Range approval certification or application for certification.

Schedule of range availability or proposed course schedule.

List of training motorcycles including VIN # or plan to acquire them.

Maintenance records of owned motorcycles (if available).

Copies of policies or quotes to obtain required insurance.

Business plan showing anticipated costs and revenues to determine viability

Policy and procedures manual for course delivery, site and equipment maintenance.

COMMONWEALTH OF KENTUCKY

MOTORCYCLE SAFETY EDUCATION PROGRAM

TRAINING PROVIDER APPLICATION

Training Provider Organization Name: _______________________________________________________

Address: ______________________________________________________________________________

City: _______________________________ State: ____________ Zip Code: ___________________

Owner / Chief Official: __________________________________________________________________

Telephone Number: _________________Email Address: _______________________________________

Student Contact Name / Title: _____________________________________________________________

Telephone Number: _________________ Email Address: _______________________________________

Financial Officer Name / Title: (can answer invoice questions) ________________________________________________

Telephone Number: _________________ Email Address: _______________________________________

Curriculum(s): (Circle all that Apply) MSF Total Control HDRA Motorcycle Ohio Other If Other, then please provide a copy of the curriculum to be taught including course materials.

Course(s) to be offered: ___________________________________________________________________

Please attach a proposed schedule

Range Address: (if different than above) _________________________________________________________

Classroom Address: (if different than above) _____________________________________________________

Do you own the range where classes will be conducted? Yes or No If No do you have a letter of agreement with the property owner? Yes or No If Yes, please provide a copy of that agreement.

Do you have enclosed storage facilities for the training motorcycles? Yes or No

If No please provide a plan to acquire a storage unit(s).

Will the training motorcycles be stored at the range facility? Yes or No If No please provide storage address: ________________________________________________ Is it mobile storage (trailer)? Yes or No

Do you own the classroom where classes will be conducted? Yes or No If No do you have a letter of agreement with the property owner? Yes or No If Yes, please provide a copy of that agreement.

Is the classroom large enough to seat all students and instructors comfortably with a writing surface for each student? Yes or No

Is the classroom mobile (trailer)? Yes or No

Are restrooms available at both your classroom and range facilities? Yes or No If No please provide a plan to provide these.

Are the classroom and range facilities ADA compliant? Yes or No

Do you have certified instructors in your area willing to provide training? Yes or No

If Yes, then please provide a list of those instructors along with their certification number.

If No, do you have a list of potential instructors who will require certification? Yes or No

If Yes, then please provide the list of candidates with contact information.

Have you read the administrative regulations and contract terms for the program? Yes or No

Are you willing to, and can you abide by all listed requirements? Yes or No

I agree to abide by all requirements stated in Motorcycle Education Program statutes and administrative regulations concerning training providers. I understand that if I violate any of the requirements as provided in the statutes or regulation, the cabinet is empowered to revoke or deny my approval.

I certify that the information given in this application form is correct and complete to the best of my knowledge. I am aware that falsification of any information may result in denial or revocation of approval.

Signature of Applicant: ______________________________________ Date: __________________

Training Provider Organization Name: _______________________________________________________