Wheelchair and Scooter Assist eForm

Customer details

Name

First name*

Last name*

Date of birth

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

Postal address*

Suburb

Postcode

Membership details

Are you an existing RACV member?

Yes

Member number

Emergency contact details

Emergency contact name*

Emergency contact number*

Retail partner details

Retail partner name*

Purchaser accepts the 12 month RACV Wheelchair and Scooter 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.*

Keep me up to date on the latest RACV product offers, benefits and services

_{The RACV privacy charter explains how we collect, handle and safeguard your personal information. You can get a copy from any RACV shop or at www.racv.com.au/privacy.}