AASA:: NationalRaceLicences

National Race Licence Application

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New Applicants

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Medical Information Acknowledgement

To obtain or renew your Australian Auto-Sport Alliance the Medical Examination Record found at the link below is to be completed by yourself and your doctor and uploaded with this application. Please return to this page when you have completed the Medical Examination Record with your doctor.

DOWNLOAD & PRINT THE MEDICAL EXAMINATION RECORD HERE

Please upload your latest Medical Document to continue, if you do not have a copy please contact the AASA Office on 03 5721 7800. *

Application Details

Are you renewing, or is this a new application? *

RenewalNew Application

Personal Details

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 14 or older to apply this licence.

Date of Birth *

Country of Birth *

Are you an Australian citizen *

YesNo

If No, Nationality on Passport? *

Emergency Contact

Emergency Contact Name *

Emergency Contact Number *

Race Information

Have you competed in a motor racing event in the last 12 months? *

YesNo

If yes, name of last event competed in *

Date *

Do you currently have a licence from another sanctioning body? *

YesNo

Who is the issuing body? *

Provide your licence number from the issuing body *

Licence level from the issuing body *

Those people wishing to apply for a new Licence please supply details of competition history for the past 12 months. *

Please check the box below if you have previously only held a Club Level Licence I have only previously held a Club Level Licence

Please provide details of at least three (3) Lap Dash events where the Clerk of Course has provided proof of completion of a satisfactory level of competition. *

Do you wish to undertake an Observed Licence Test? *

YesNo

Medical Information

Gender *

MaleFemale

Tetanus Immunisation Date

Blood Type *

Allergies?

YesNo

Please list *

Is this your first Motor Racing medical examination? *

YesNo

Since your last Motor Racing medical examination has your health status changed? *

YesNo

Since your last Motor Racing medical examination have you suffered from any injury or been involved in any accident of any kind? *

YesNo

Have you ever suffered from:

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

Any nervous disorder – including nerves, neurasthenia or anxiety state? *

YesNo

Anaemia or any other blood disease? *

YesNo

Headaches? *

YesNo

Deafness or noises in the ear? *

YesNo

Fits or convulsions, turns or blackouts, fainting or giddiness? *

YesNo

Earache or discharge from the ear? *

YesNo

Head injury or concussion? *

YesNo

Chronic sinusitis? *

YesNo

Tuberculosis or other lung trouble? *

YesNo

Any surgical operation? *

YesNo

Rheumatic fever or heart disease? *

YesNo

Any injuries related to motorsport? *

YesNo

Indigestion, gastric or duodenal ulcer? *

YesNo

Any other injuries? *

YesNo

Kidney or bladder trouble? *

YesNo

Any illness not already mentioned? *

YesNo

Diabetes?*

YesNo

Are you taking or have you taken any injections, tablets or other forms of medication? *

YesNo

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

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.

Medical Declaration (An applicant making a false declaration is liable to refusal or cancellation of licence.) *

I hereby declare I have read the questions above and that the answers I have given are to the best of my belief true, correct and complete in every detail. I further declare that I have not withheld any information or made any statements which are calculated to conceal any reason that could result in the refusal of this licence. I confirm I am aware that if any of the answers given above are affected by any event which might occur during the currency of the licence issued as result of this medical examination I will report such alterations to Australian Auto-Sport Alliance Pty Ltd. forthwith. I undertake not to use any drugs or medication which could have the capacity of affecting my driving ability within 48 hours of my competition and formally agree I will submit to any testing for drugs as may be considered to be justified by any Australian Auto-Sport Alliance Pty Ltd. appointed doctor. I hereby give my full authority to Australian Auto-Sport Alliance Pty Ltd. medical officers to obtain information from relevant clinical records, x-ray and pathology reports from my doctor if required to support this application

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

Payment Details

National Race Licence

Price: $ 225.00

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

YesNo

Tarmac Rally Endorsement

Price: $ 50

Would you like to endorse your National Race Licence to include National Off Road Racing Events

YesNo

National Off Road Racing Endorsement

Price: $ 50

Would you like to endorse your National Race Licence to include National Speedway Events?

YesNo

National Speedway Endorsement

Price: $ 50

Do you have a coupon?

APPLY Coupon

Yearly Licence Fee

Price: $ 225.00

Transaction Fee: $ 4.35

Total $ 229.35

Credit Card *

Card Number *

Expiration Date *

Security Code *

Cardholder Name *

National Race Licence Application

Medical Information Acknowledgement

Application Details

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.

Emergency Contact

Race Information

Medical Information

Have you ever suffered from:

Personal Accident Weekly Benefit

Click here for Flexible Insurance Options Overview

Payment Details

National Race Licence

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.