Form HSMV77058 "Rider Coach Apprentice Program Application" - Florida

What Is Form HSMV77058?

This is a legal form that was released by the Florida Department of Highway Safety and Motor Vehicles - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2010;
  • The latest edition provided by the Florida Department of Highway Safety and Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HSMV77058 by clicking the link below or browse more documents and templates provided by the Florida Department of Highway Safety and Motor Vehicles.

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Download Form HSMV77058 "Rider Coach Apprentice Program Application" - Florida

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FRTP use only:
Date Received
DL Record Checked
MC Endorsement
RCAP Sent
Accepted/Un-Accepted
Rider Coach Apprentice Program Application
APPLICATION CAN BE TYPED IN BUT INFORMATION CANNOT BE STORED
Part A. APPRENTICE DATA
First Name (Proper)
MI
Last Name
Common First Name
Street
Birth Date
Social Security #
FL
Apartment
Drivers License #
State
-
FL
City
State
Zip Code + 0000
County
Employer
Occupation
Home Phone:
Fax Number:
Work Phone:
Cell Phone:
E-Mail:
Ext.
DO NOT call at work
RCP schedule format preferred?
Three weekend schedule
Seven day schedule
No preference
Part B. MOTORCYCLE RIDING EXPERIENCE
Do you currently own or operate a motorcycle on frequent and routine
YES
NO
basis on public roadways? ***
Do you currently have a motorcycle endorsement?***
YES
NO
How many years have you been riding?
How many miles do routinely ride each year?
Date you completed the Basic RiderCourse (BRC)? ***
Date:
Part C. DRIVING RECORD, CRIMINAL HISTORY AND HEALTH ISSUES
Has your driver's license been suspended/revoked?
Date:
YES
NO
Have you been convicted of a DUI?
Date:
YES
NO
Have you been convicted of a misdemeanor or felony?
Date:
YES
NO
Do you have any medical conditions that could hinder or
limit your ability to Coach?
YES
NO
If you answered "yes" to any question in Part C, use a separate sheet of paper to explain.
Part D. ITEMS RIDER COACH APPRENTICE OR SPONSOR MUST PROVIDE.
1.
Criminal History Information (background check) ***
http://www.fdle.state.fl.us/CriminalHistory/
2.
Drivers Licenses Record check ***
3 year driver history record. If Candidate has been licensed outside of Florida in the past 3 years,
candidate must obtain a Drivers Licenses Record Check from the State of licensing.
3.
Completed original application mailed to address provided on the last page ***
4.
A copy of the candidates most recent (within 1 year) Basic RiderCourse completion card ***
*** indicates required prerequisite for initial acceptance.
HSMV 77058 (Revised 08/10 )
Page 1 of 2
FRTP use only:
Date Received
DL Record Checked
MC Endorsement
RCAP Sent
Accepted/Un-Accepted
Rider Coach Apprentice Program Application
APPLICATION CAN BE TYPED IN BUT INFORMATION CANNOT BE STORED
Part A. APPRENTICE DATA
First Name (Proper)
MI
Last Name
Common First Name
Street
Birth Date
Social Security #
FL
Apartment
Drivers License #
State
-
FL
City
State
Zip Code + 0000
County
Employer
Occupation
Home Phone:
Fax Number:
Work Phone:
Cell Phone:
E-Mail:
Ext.
DO NOT call at work
RCP schedule format preferred?
Three weekend schedule
Seven day schedule
No preference
Part B. MOTORCYCLE RIDING EXPERIENCE
Do you currently own or operate a motorcycle on frequent and routine
YES
NO
basis on public roadways? ***
Do you currently have a motorcycle endorsement?***
YES
NO
How many years have you been riding?
How many miles do routinely ride each year?
Date you completed the Basic RiderCourse (BRC)? ***
Date:
Part C. DRIVING RECORD, CRIMINAL HISTORY AND HEALTH ISSUES
Has your driver's license been suspended/revoked?
Date:
YES
NO
Have you been convicted of a DUI?
Date:
YES
NO
Have you been convicted of a misdemeanor or felony?
Date:
YES
NO
Do you have any medical conditions that could hinder or
limit your ability to Coach?
YES
NO
If you answered "yes" to any question in Part C, use a separate sheet of paper to explain.
Part D. ITEMS RIDER COACH APPRENTICE OR SPONSOR MUST PROVIDE.
1.
Criminal History Information (background check) ***
http://www.fdle.state.fl.us/CriminalHistory/
2.
Drivers Licenses Record check ***
3 year driver history record. If Candidate has been licensed outside of Florida in the past 3 years,
candidate must obtain a Drivers Licenses Record Check from the State of licensing.
3.
Completed original application mailed to address provided on the last page ***
4.
A copy of the candidates most recent (within 1 year) Basic RiderCourse completion card ***
*** indicates required prerequisite for initial acceptance.
HSMV 77058 (Revised 08/10 )
Page 1 of 2
Rider Coach Apprentice Application (continued)
Part E. RIDER COACH APPRENTICE AND SPONSOR AGREEMENT AND SIGNATURE
For the Rider Coach Apprentice:
I understand that completion of this application does not guarantee acceptance into the FRTP Rider
Coach Apprentice Program. My criminal history, driving record, application, and BRC card copy will be
evaluated by the FRTP Staff prior to acceptance or denial into the FRTP Rider Coach Apprentice
Program.
Additionally, in signing my name, I agree to participate in the Basic RiderCourses as an observer,
student rider, or range assistant only.
Providing any coaching tips or riding techniques is strictly forbidden during any FRTP
sponsored training event . Failure to comply with this could result in immediate rejection of
your application. This is a violation of the FRTP Sponsor's contract.
My signature below indicates that the information I have provided in this application is complete and
accurate. Also, this application is only valid for one year from the date of acceptance into the FRTP
Rider Coach Apprentice Program.
For the Rider Coach Apprentice Sponsor/Administrator:
I understand that I, the Sponsor/Administrator, will ensure that the Rider Coach Apprentice will be
provided with all vital information concerning FRTP policies and FRTP Program Contract and will be
adequately prepared in both classroom and range presentations prior to requesting an RCAP
Evaluation and selection to a RiderCoach Preparation course. If there are any changes in the status of
this Apprentice with the Sponsor/Administrator, I will promptly notify FRTP.
I have personally screened this application. To the best of my knowledge, it is complete and
accurate.
Signature
Date
Printed Name
Sponsor Name and RERP#
Email
Phone Number
1. Maintain a copy of the application for both the Sponsor and Apprentice.
2. Mail completed application with original signatures and other required paperwork to:
FRTP/Ray Zurenda
4100 W. M.L.King Jr. Blvd.
Tampa, FL 33614
Contact the FRTP office at (727 ) 365 -9950 or at FRTP@flhsmv.gov with any question.
*** indicates required prerequisite for initial acceptance.
HSMV 77058 (Revised 08/10 )
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