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WAKEFIELD DAY LICENCE
Multi Day (Max 2 days)
Single Day Event Date
Multi Day Event Start Date
Multi Day Event End Date
Please ensure the dates entered are
. Applications containing non consecutive dates will not be valid.
Address (Street 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)
Country of Birth
Date of Birth
IMPORTANT: AASA Day Licence applications for 14-17 year old’s cannot be submitted online. Please complete the application form
and submit it directly to the AASA office.
Are you an Australian citizen
Have you previously held a Motor Racing Licence?
If yes, last year held?
Previous Licence No.
Tetanus Immunisation Date
Have you ever been diagnosed as having and/or had treatment for: (Please tick)
1. A psychiatric or psychological illness?
2. Persistent or severe headache, head injury, epilepsy, seizure or loss of consciousness?
3. Heart or lung disease, including infection, blood vessel disease, hypertension, coronary bypass, angioplasty or other surgical procedure?
4. Cancer, diabetes, kidney, liver, thyroid, gastrointestinal, blood pressure disorders, including any associated surgical procedures?
5. Any other significant illness, injury or surgery not already noted?
6. Have you taken any medications, including self-medication or alternative therapies?
7. Do you have any hearing impairment or loss?
8. Do you suffer from any hearing disorder including tinnitus?
9. Is your eyesight normal in both eyes for distance vision?
If NO do you wear spectacles or contact lens?
10. When did you last have a medical examination?
Please give full details if you answered YES to any of the above questions:
Disclaimers & Payment
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
Competency Declaration by Club/ Organization or Individual.
This applicant is recommended by Club/ Organization/ Individual who is personally known to AASA
Name of Club/ Organization/ Individual:
Wakefield Single Day Event Day Licence
Wakefield Multi Day Event Day Licence
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.