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:

Name

Relationship

Phone Numbers

 

 

 

 

 

 

 

 

 

 

 

 

Authorization for Release of Information

 

In connection with my application for employment/promotion/tenancy/care provider, including any contract for services, with you, I understand that a consumer report containing background or credit information and other public information may be requested by RIFNA, Inc.  I authorize, without reservation, any party or agency of RIFNA, Inc. or one of its agents to request and/or furnish abovementioned information.  I have a right to make a request to RIFNA, Inc. of the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which RIFNA, Inc. has previously furnished within the two-year periods preceding my request.

 

By signing this document, I verify that, to the best of my knowledge, the above information is true, and I have authorized release of information to RIFNA, Inc. to be verified. 

 

__________________________________________________________________

Signature                                                   Date: MM/DD/YY

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