# of  years riding:

Disciplines taught:

Western      Dressage  Hunter Equitation

RIFNA Coach’s name :

Certification:

Expiration Date:

Current Employer:

Previous Employers:

Do you have professional liability insurance?

Yes               No

Policy carrier/number:

Limits:

$

Do you have any prior claims?        No             Yes*

*If yes, please indicate outcome:

Do you have, or have you had, any civil or criminal complains filed against you?        No         Yes*

*If yes, please indicate outcome:

Are you CPR Certified?**

Yes   (Expiration Date:  __________)            No

(**Must submit proof)

Scheduled for training on ________________________

Please indicate three (3) professional references that we may contact:

Name	Relationship	Phone Numbers