BusinessWise Membership Application

Fields marked (*) are mandatory and must be completed for your application to be processed.

Business Details

Business Name *

ABN# OR ACN# *

Business Phone *

Street Address - line 1 *

Street Address - line 2

Street Address Suburb *

Street Address State *

Street Address Postcode *

Postal Address - line 1 *

Postal Address - line 2

Postal Address Suburb *

Postal Address State *

Postal Address Postcode *

Primary Contact Details

For Membership purposes e.g. Voting Rights

Title *

Given Name(s) *

Last Name *

Contact number *

Mobile Number

Contact email *

Please send me email communications keeping me up to date with news, promotions and Member information.

Secondary Contact Details

For account management purposes

Title *

Given Name(s) *

Last Name *

Contact number *

Mobile Number

Contact email *

Membership Details

Is the business currently an NRMA member?

Yes No

How many vehicles will require cover?

1-5 5-10 10-15 15-20 20-25 25-30

Vehicle + Subscription Package Details

In order to calculate the correct cost for your BusinessWise membership - please enter all the fields below for each vehicle you wish to cover. If you are not sure of Make and Model you may leave these blank.

Rego	Make	Model	Vehicle Size	Vehicle Cover

NRMA BusinessWise Membership Annual Fee (mandatory)	$
Total Cost - Including Discount	Total $
You have enjoyed a total saving of $ on this BusinessWise Membership package.

Declaration

Declaration *

When you pay for your membership you agree to become a Member of the National Roads and Motorists' Association Limited. This means that you agree to be bound by Your Membership Entitlements, and the Constitution of National Roads and Motorists' Association Limited.

Do you agree to become a member of National Roads and Motorists' Association Limited and to be bound by its constitution?

Yes No