REGISTRATION

First Name:*
Surname:*
Account Password:*
Email:*
Home Telephone:*
Work Telephone
Mobile
Address:*
Suburb*
State:*
Post Code:*
Preferred Contact Method/s:*
Mail
Telephone
Mobile
SMS
Email
Date of Birth (DD/MM/YY):*
Gender:*
Male
Female
Occupation:
Licence Type/Class:
Licence Number:
Have you had a car accident in the last 3yrs?
Yes - at fault
Yes - not at fault
No
Received a speeding fine in the last 12mths?
Yes : 10-20ks over
Yes : 20-29ks over
Yes : 30+ over
No
Charged with Drink/Drug/Wreckless driving?
Yes - Alcohol
Yes - Drugs
Yes - Wreckless
No
Other recorded convictions?
Yes - We will contact you for info
No
Make of vehicle*
Model of vehicle*
Year of vehicle*
Colour of vehicle*
Registration Plate:*
Current Mileage:*
Engine Size:
Condition of vehicle
Paintwork / Vehicle damage (If yes, details):
Number of Doors
Is the vehicle Insured?*
Yes
No
Insurance provider:
Main Purpose:*
Private Use
To/From Work
Business Use
Other
Are you the owner/main driver?*
Yes - Owner (Not Main Driver)
Yes - Owner (& Main Driver)
Not Owner, Yes Main Driver
Not Owner, Not Main Driver
Is the vehicle garaged over night?
Yes - Always
Yes - Mostly
Yes - Sometimes
No
Does the vehicle have a breakdown service?
Yes
No
Approximate daily mileage? (Kms)
Approximate weekly mileage? (Kms)
Approximate mileage to/from work? (Kms)
Similar travel per month?
Yes
No
Is the vehicle parked on the street/carpark during the day/at work?
Street
Carpark - Public
Carpark - Private
List any major routes/highways/roads/motorways travelled in a week:
Do you understand the FreePetrol.com.au program?*
Yes
No


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