Road Guardians

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MEMBERSHIP LEVEL

Certified (Requires that you are currently certified in ASMI Basic and Advanced, CPR certification and have completed a Motorcycle Safety Rider Education class. You will be asked to attach, fax or send documentation. If you do not have documentation please apply for the RG program. Advancement to Certified RG can occur at any time once you have complete the required documentation)

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PERSONAL INFORMATION

* First Name

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MOTORCYCLES

* Primary Make

Primary Model

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Secondary Make

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ASMI BYSTANDER ASSISTANCE CLASS

* ASMI Basic Class Date

* ASMI Basic Location

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ASMI Refresher Date

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ASMI Certified Instructor

MOTORCYCLE SAFETY RIDER COURSE

* Name of Provider Organization
*
* Class Name Attended
*
* Date Attended
*
* Location of Class (City and State)
*
Upload Completion Certificate Below (or fax: 262-436-0278)

Upload Drivers License Below (optional) or fax: 262-436-0278 (black out your DL#)

Safety Instructor (affiliated with training site) Yes

CPR CERTIFICATION

* Class Date
*
Upload CPR Card Below (or fax: 262-436-0278)

Check all that Apply *
	AHA
	ARC
	ASHI

MOTORCYCLE ASSOCIATIONS (Check all that Apply)

	ABATE
	AMA
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	HOG
	BMWOA
	GWRRA
	CMA
	STAR

OTHER (Check all that Apply)

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