Southern Mississippi Motorcycle Training, LLC
P.O. Box 14043, Jackson, Ms. 39236 
Phone: 601-238-5027

	Date: ______________________                           

Name: ________________________________          Hm. Phone:  _______________________ 
Address: ______________________________          Cell Phone: _______________________                    City:    ______________________________           State: __________ Zip: __________ 
D.O.B.: __________    Gender:   ________    
	Have you ever ridden a motorcycle? 	
Do you currently own a motorcycle? If so, what kind and how long? _________________________ 
Do you have any physical handicaps or limitations that would prohibit you from operating a motorcycle?  _____________________________________________________________________ 
	Are you currently taking any kind of medication(s)?	______________________ 
	How did you learn of this course? _____________________________________________________
Basic Rider Course
14 hrs of instruction $250.00
Motorcycle provided	Experienced Rider Course
$125.00 	Individualized Lessons
$325.00	

**Students must be of driving age and have parent or guardian permission to participate in       
   the motorcycle course. 

Signature:         _______________________________________

Return completed application to the address listed above along with a money order or cashier’s check made payable to Southern Mississippi Motorcycle Training. Payment must be received 5 days prior to class.  Minimum notice of 4 days required to cancel from class or tuition forfeited. 
$40.00 N.S.F. fee + bank charge, for all returned checks. 
All students will be notified upon receipt of application and class fee. 

Students attending Southern MS Motorcycle Training classes may be photographed by newspaper or television reporters/photographers, staff members, or others involved with the program. These photographs may appear without compensation in newspapers or in productions, publications, on the Web, or other printed or electronic materials related to the role and function of Southern MS Motorcycle Training.  If you do not want to be photographed, please initial here. __________