Bike Assist eForm

Customer details

Name

First name*

Last name*

Date of birth

Contact details

Email*

Another Email

Contact number*

Street address*

Suburb*

Postcode*

Postal address

Postal address is the same as residential address

Add a different postal address

Address*

Suburb*

Postcode*

State

Membership details

Are you an existing RACV member?

Yes

Membership number

Retail partner details

Retail partner name*

Acquisition

Purchased

Gifted

Purchaser accepts the 12 month RACV Bike Assist offer and understands that by doing so they are becoming a member of RACV and will be subject to the RACV Roadside Assistance Terms and Conditions. Purchaser agrees to this Dealership sharing their personal information with RACV for the purpose of issuing a membership and purchaser has been advised that RACV will deal with their information in accordance with its Privacy Charter, a copy of which can be viewed at www.racv.com.au/privacy.*