Riders Interscholastic Federation of North America, Inc. (RIFNA)

Coach Certification Application

Applicant Verification Data

In order to process your application; please provide the following information. Include your exact legal name and any other name(s) you may have used in the last seven (07) years. Please PRINT CLEARLY AND IN INK. 

First Name:

Middle Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Date of birth:

Social Security Number

Email:

Driver’s License Info:

Number:

State:

Please list any other name(s) used and indicate dates used.

Other Name Used:

                                                                                                                                     Used From                Used Until

Other Name Used:

                                                                                                                                   Used From                Used Until

Past Residence Data

Applicant must provide city, county and state information for residence covering a period of seven (07) years. Begin with your most current address.

From:			To:
	MM/YYYY				MM/YYYY
City		County	State			Zip

From:			To:
	MM/YYYY				MM/YYYY
City		County	State			Zip

From:   To:     MM/YYYY   MM/YYYY         City County State Zip

Farm:

# of years Training:

# of years riding:

Disciplines taught:

Dressage           Western  Hunter

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:

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