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Club Racing Licence Application
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Club Racing Licence Application
Club Racing Licence Application
aasa
2019-01-10T13:19:56+00:00
Please complete the online application below.
Licence Venue Details
At which venue will you be using this licence for your first event?
Venue
*
Please Select
Winton Motor Raceway
Wakefield Park
Mallala Motorsport Park
Barbagallo Raceway
Sydney Motorsport Park
Morgan Park Raceway
The Bend Motorsport Park
Calder Park Raceway
Logic Centre Barnawartha
Collie Motorplex
DECA Wodonga
Hampton Downs Motorsport Park Waikato NZ
Bruce McLaren Motorsport Park Taupo NZ
Other
Please enter venue
*
Personal Details
First Name
*
Last Name
*
Mobile
*
Occupation
*
Email
*
Address (Postal Address)
*
As this information is used for mail merging posted items, please ensure your address is entered with the correct casing. eg. 1 Main Street.
Address (Address Line 2)
City
*
State
*
Please Select
ACT
QLD
NSW
SA
WA
NT
VIC
TAS
New Zealand
Postcode
*
Country
*
Age
*
Country of Birth
*
Date of Birth
*
IMPORTANT: AASA Club Racing Licence applications for 14-17 year old’s cannot be submitted online. Please complete the application form
found here
and submit it directly to the AASA office.
Are you an Australian citizen
*
Yes
No
Gender
*
Male
Female
Have you previously held a Motor Racing Licence?
*
Yes
No
If yes, last year held?
*
Previous Licence No.
*
Issuing Body
Please select
AASA
CAMS
ANDRA
KA
Racers
Other
Medical Information
Blood group
*
Please select
A+
A-
B+
B-
O+
O-
AB+
AB-
Unknown
Tetanus Immunisation Date
Allergies?
Yes
No
Please list
*
Have you ever been diagnosed as having and/or had treatment for: (Please tick)
1. A psychiatric or psychological illness?
*
Yes
No
2. Persistent or severe headache, head injury, epilepsy, seizure or loss of consciousness?
*
Yes
No
3. Heart or lung disease, including infection, blood vessel disease, hypertension, coronary bypass, angioplasty or other surgical procedure?
*
Yes
No
4. Cancer, diabetes, kidney, liver, thyroid, gastrointestinal, blood pressure disorders, including any associated surgical procedures?
*
Yes
No
5. Any other significant illness, injury or surgery not already noted?
*
Yes
No
6. Have you taken any medications, including self-medication or alternative therapies?
*
Yes
No
7. Do you have any hearing impairment or loss?
*
Yes
No
8. Do you suffer from any hearing disorder including tinnitus?
*
Yes
No
9. Is your eyesight normal in both eyes for distance vision?
*
Yes
No
If NO do you wear spectacles or contact lens?
*
Yes
No
10. When did you last have a medical examination?
*
Please give full details if you answered YES to any of the above questions:
*
Personal Accident Weekly Benefit
The Flexible Insurance Options product overview can be found at the link below.
Please ensure that you have read this document thoroughly before apply for this additional cover.
FLEXIBLE INSURANCE OPTIONS OVERVEW →
Would you like to increase your personal accident weekly benefit provided under an AASA permit in the event of a claim?
*
Yes
No
The standard benefit provided is $900 per week. Please refer to the online insurance summary for additional details. This cover only applies for claims which occur at an AASA sanctioned event.
Please select the amount you would like this increased to:
*
$1,100 per week (cost is $500)
$1,300 per week (cost is $750)
$1,500 per week (cost is $1,000)
Benefit Overview Declaration
*
I declare that I have read the Flexible Insurance Options overview and fully understand all aspects of this insurance product
Increase weekly benefits to $1,100
*
Price:
$ 500.00
Increase weekly benefits to $1,300
*
Price:
$ 750.00
Increase weekly benefits to $1,500
*
Price:
$ 1,000.00
Disclaimers & Payment
Declaration:
1/ I certify that the statements made regarding my psychological and physical condition and any previous illness are true and accurate.
2/ I understand that I will not use any drug considered illegal.
3/ I authorize any hospital or medical practitioner to furnish information relevant to my medical condition to a Medical Assessor in order to determine competition fitness.
4/ I acknowledge that motorsport is dangerous and agree that AASA shall not be under any liability whatsoever for any death or bodily injury, loss or damage which I may incur, howsoever such death or bodily injury, loss or damage is caused, by negligence or otherwise.
For Female Applicants:
I agree to refrain from participating in any motor sport events except touring events if I am aware that I am or may be pregnant, and to abide by AASA’s HSE policy regulations.
Female Driver Acknowledgement
*
I AGREE THAT AS A FEMALE I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT
Club Racing Licence Fee
*
Price:
$ 85.00
Coupon
Total
$ 0.00
Declaration
*
I declare that all information provided for the purposes of this application is true and accurate to the best of my knowledge. I understand that in providing false or misleading information my licence may be suspended or cancelled, and I may not be afforded the coverage of the Personal Accident and Injury insurance provided under the AASA Insurance Scheme. I agree to comply with the AASA National Competition Rules at all times when participating in a AASA Sanctioned Event.
Credit Card
*
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Expiration Date
Security Code
Cardholder Name