AASA:: ExtremeEventLicences

Extreme Event Licence Application

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New Applicants

Personal Details

Please enter your email address *

Confirm email *

What type of Extreme Event Licence would you like? *

Extreme Event LicenceJunior Lawn Mower/Tractor Pull

Country *

First Name *

Last Name *

Mobile No. *

Occupation *

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.

City *

State *

Post Code *

Your current profile picture

This image will be used on your licence.

Would you like to change your image?

YesNo

Profile Picture

Please upload a close up headshot for your licence photo.
Please ensure you upload a normal licence / passport style photo as shown here.
Not a photo of your entire licence.

You must be 6 or older to apply this licence.

Date of Birth *

Country of Birth *

Are you an Australian citizen *

YesNo

Gender *

MaleFemale

Have you previously held an extreme event licence? *

YesNo

If yes, last year held? *

Previous Licence No. *

Issuing Body

Medical Information

Blood group *

Tetanus Immunisation Date

Allergies?

YesNo

Please list *

Have you ever been diagnosed as having and/or had treatment for: (Please tick)

1. A psychiatric or psychological illness? *

YesNo

2. Persistent or severe headache, head injury, epilepsy, seizure or loss of consciousness? *

YesNo

3. Heart or lung disease, including infection, blood vessel disease, hypertension, coronary bypass, angioplasty or other surgical procedure? *

YesNo

4. Cancer, diabetes, kidney, liver, thyroid, gastrointestinal, blood pressure disorders, including any associated surgical procedures? *

YesNo

5. Any other significant illness, injury or surgery not already noted? *

YesNo

6. Have you taken any medications, including self-medication or alternative therapies? *

YesNo

7. Do you have any hearing impairment or loss? *

YesNo

8. Do you suffer from any hearing disorder including tinnitus? *

YesNo

9. Is your eyesight normal in both eyes for distance vision? *

YesNo

If NO do you wear spectacles or contact lens? *

YesNo

10. When did you last have a medical examination? *

Please give full details if you answered YES to any of the above questions: *

Event

Event Attending *

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.

Click here for Flexible Insurance Options Overview

Would you like to increase your personal accident weekly benefit provided under an AASA permit in the event of a claim? *

YesNo

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

Price:

Benefit Overview Declaration *

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

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.

Famale Driver Acknowledgement *

I AGREE THAT AS A FEMALE I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT

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.

Do you have a coupon?

APPLY Coupon

Yearly Licence Fee

Price: $ 80.00

Transaction Fee: $ 1.74

Total $ 81.74

Credit Card *

Card Number *

Expiration Date *

Security Code *

Cardholder Name *

Extreme Event Licence Application

Personal Details

Profile Picture

Please upload a close up headshot for your licence photo. Please ensure you upload a normal licence / passport style photo as shown here. Not a photo of your entire licence.

Medical Information

Event

Personal Accident Weekly Benefit

Click here for Flexible Insurance Options Overview

Disclaimers & Payment

Credit Card *

Please upload a close up headshot for your licence photo.
Please ensure you upload a normal licence / passport style photo as shown here.
Not a photo of your entire licence.