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National Karting Licence
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National Karting Licence
National Karting Licence
aasa
2017-12-19T11:24:01+00:00
Please complete the online application below.
Personal Details
First Name
*
Last Name
*
Mobile
*
Email
*
Address ( Street Address )
*
Address ( Line 2 )
City
*
State
*
Please Select
NSW
VIC
QLD
WA
TAS
SA
ACT
NT
Postcode
*
Country
*
Date of Birth
*
Australian Citzenship
*
Yes
No
If No, Nationality on passport?
*
Have you competed in a kart racing event in the last 12 months?
*
Yes
No
If yes, name of last event competed in:
*
Date of Event
*
Are you a current licence holder from another issuing body?
*
Yes
No
Licence holders from another issuing body, please supply details of competition history for the past 12 months.
*
For those people who have previously only held a Club level licence must attach a history of at least three (3) events where the Clerk of Course has provided proof of completion of a satisfactory level of competition.
Upload additional listings if necessary
Accepted file types: doc, pdf.
Medical Declaration
Information given in this statement will be treated in total confidence although the Chief Medical Officer, upon examining this document, is obliged to advise the Organiser of the Event if, at any time, a participant’s medical condition poses an unacceptable risk to that individual or to a co-driver, spectator, race official or any other person attending the Event.
Age
*
Current Body Weight
Height
*
Online applications can only be submitted for applicants over the age of 18.
For applicants aged 16-18 please download the PDF
application form here
, and submit to AASA.
VISION
While driving, do you wear glasses or contact lenses?
*
Yes
No
Do you have any problems with colour vision or distance vision?
*
Yes
No
If Yes to either of the above, please detail:
*
MOBILITY
Do you have any restriction of movement in your limbs?
*
Yes
No
Do you have any restriction of your ability to enter or leave your vehicle?
*
Yes
No
If Yes to either of the above, please detail:
*
MEDICAL
Have you ever suffered from any of the following:
Any nervous disorder including nerves, neurasthenia or anxiety state?
*
Yes
No
Fits, convulsions, turns, blackouts, fainting or giddiness
*
Yes
No
Headaches
*
Yes
No
Deafness or noises in the ear
*
Yes
No
Head injury or concussion
*
Yes
No
Earache or discharge from the ear
*
Yes
No
Tuberculosis or lung trouble
*
Yes
No
Chronic Sinusitis
*
Yes
No
Rheumatic Fever or Heart Disease
*
Yes
No
Any surgical operations
*
Yes
No
Indigestion, gastric or duodenal ulcer
*
Yes
No
Any injuries related to motorsport
*
Yes
No
Kidney or bladder trouble
*
Yes
No
Any other injuries
*
Yes
No
Diabetes
*
Yes
No
Any illnesses not already mentioned
*
Yes
No
Anaemia or other blood disease
*
Yes
No
Any known allergies
*
Yes
No
If Yes to any of the above, give full details:
*
MEDICAL
Please list all medication that you may be taking while attending the event – include prescription, over the counter and health shop preparations.
Name of Drug
Strength
Number take p/day
Name of Drug
Strength
Number take p/day
Name of Drug
Strength
Number take p/day
Name of Drug
Strength
Number take p/day
Medical Declaration
Please carefully read the following statement
*
I certify that this is a true statement of my medical condition. I will advise the CMO of any subsequent medical problems that may arise or any medical treatment that may affect my ability to participate in this event.
General Declaration
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.
Payment
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)
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
National Kart Licence Application Fee
*
Price:
$ 125.00
Total
$ 0.00
Coupon
Credit Card
*
American Express
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
Expiration Date
Security Code
Cardholder Name