N.10 - REP Levels Data Update/Renewal Form Rev 2-06

N.10 REP Levels Data Update Form

/ GOLD WING ROAD RIDERS ASSOCIATION, INC. /
RIDER EDUCATION
LEVELS DATA UPDATE FORM
Date of Update(MM/DD/YY) / /
Submitted by: / Membership #:
District: / Chapter:
Please Update the REP Database Records as Follows:
(Check the appropriate field you want to change and enter the information)
Update Rider Information / Update Co-Rider Information
Rider: / Co-Rider:
Membership #: / Membership #:
Change of Address/Chapter/District Designation (must be performed by the Member Contacting Phoenix)
Update Rider Level Starting Date / Update Co-Rider Level Starting Date
Date current level was achieved / / / Date current level was achieved / /
Update Rider Safe Miles / Update Co-Rider Safe Miles
Safe Miles: / (5K mile increments) / Safe Miles: / (5K mile increments)
Safe Miles Pin/Rocker(s) needed ($2.00 USD per Pin/Rocker) / Total Pin/Rocker Cost / $
Update Rider High Mileage (miles or km) / Update Co-Rider High Mileage (miles or km)
High Miles: / (50K increments) / High Miles: / (50K increments)
High Mileage Pin/Rocker(s) needed ($2.00 USD per Pin/Rocker) / Total Pin/Rocker Cost / $
Update of Rider Level Requirements / Update of Co-Rider Level Requirements
Indicate Level You Are Updating Your Requirements For / Indicate Level You Are Updating Your Requirements For
Level 2 / Level 3 / Level 4 / Level 2 / Level 3 / Level 4
Approved Rider Course: / Approved Rider Course or Co-Rider Seminar
Type: / ARCARC-RBRCBRC2TCTRCTRC-RSRCTTRC3WBRCINST / Exp. Date: / / / Type: / 2-UPCRSCRV / Exp. Date: / /
CPR or First Aid Provider: / CPR or First Aid Provider:
CPR Provider: / AHAARCASHIEMSERINSTMFANSCSJACRC / Exp. Date: / / / CPR Provider: / AHAARCASHIEMSERINSTMFANSCSJACRC / Exp. Date: / /
First Aid Provider: / AHAARCASHIEMSERINSTMFANSCSJACRC / Exp. Date: / / / First Aid Provider: / AHAARCASHIEMSERINSTMFANSCSJACRC / Exp. Date: / /
Total Pin/Patch Cost / $
Other (list):
Mail form to:
Your Distict Educator

Approved and Revised January 1, 2018