Motorsport Licensing & Event Insurance - National Tarmac Rally Licence

Personal Details

First Name*

Last Name*

Mobile*

Email*

Address ( Street Address )*

Address ( Line 2 )

City*

State*

Postcode*

Country*

Date of Birth*

Australian Citzenship*

Yes
No

If No, Nationality on passport?*

Have you competed in a motor 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

Do you have a current civil Drivers Licence?*

Yes
No

A current civil Drivers Licence is required to complete this application.

Drivers Licence No.*

State of Issue*

Expiry Date*

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.

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)

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

Benefit Overview Declaration*

I declare that I have read the Flexible Insurance Options overview and fully understand all aspects of this insurance product

Payment

National Tarmac Rally Licence Application Fee*

Price: $ 180.00

Would you like to endorse your Tarmac Rally Licence to include National Circuit Racing Events?*

Yes
No

National Circuit Racing Endorsement*

Price: $ 50.00

Would you like to endorse your Tarmac Rally Licence to include National Off Road Racing Events?*

Yes
No

National Off Road Racing Endorsement*

Price: $ 50.00

Would you like to endorse your Tarmac Rally Licence to include National Speedway Events?*

Yes
No

National Speedway Endorsement*

Price: $ 50.00

Coupon

Total

$ 0.00

Credit Card*

American Express

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

National Tarmac Rally Licence

AASA NATIONAL TARMAC RALLY LICENCE APPLICATION

Personal Details

Medical Declaration

VISION

MOBILITY

MEDICAL

MEDICAL

Medical Declaration

General Declaration

Personal Accident Weekly Benefit

Payment