SURNAME TITLE MR MRS MISS MS DR GIVEN INITIAL
POSTAL ADDRESS
NUMBER STREET NAME
SUBURB / TOWN STATE ACT NSW NT QLD SA TAS WA POSTCODE
HOME ADDRESS
HOME PHONE MOBILE PHONE WORK PHONE
EMAIL ADDRESS
VEHICLE REG YEAR (MUST BE LESS THAN 20 YEARS)
MAKE MODEL
BODY TYPE SEDAN STATION WAGON UTE COUPE VAN 4WD OTHER COLOUR
FUEL TYPE ULP PULP DIESEL LPG DUAL HYBRID TRANSMISSION AUTO MANUAL CYLINDERS
VIN NUMBER ENGINE NUMBER
MEMBERSHIP TYPE ACT- $106 NSW - $106 NT - $106 QLD - $106 SA - $99 TAS - $99 VIC - $106 WA - $99
PAYMENT DETAILS
CREDIT CARD TYPE VISA MASTERCARD BANKCARD CARD NUMBER EXPIRY MMYY
CARDHOLDER NAME
DRIVERS LICENSE NUMBER
EXISTING ROADSIDE COVER
EXPIRY DATE MONTH JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC YEAR 2006 2007 2008 2009 2010 2011
MOTORING 24-7 COVER WILL COMMENCE FROM THIS TIME
BONUS - YOU WILL GET THE EXPIRY & FOLLOWING MONTH FREE!
UP TO 14 MONTHS FOR THE PRICE OF 12 !!!
(Not to be used in conjunction with any other offer.)
SPONSOR NAME (OPTIONAL)
SEND ME INFORMATION FROM M24-7 OR PARTNERS YES NO
OOPS, WANT TO START AGAIN!
ALL OK
Smartmotoringassociation Pty Ltd. PO BOX 10123 ADELAIDE 5000 SOUTH AUSTRALIA
Phone: 1300 303 917 Fax: 08 8377 7147 E-mail: admin@smartmotoring.com.au