License Application

Applicant Info

Name*

First Middle Last

Address*

Street Address City Province Postal Code

Email Address*

Are you an Area 27 Member?*

Yes

No

Area 27 Membership Number*

Home Phone

Cell Phone

Emergency Contact*

Emergency Contact Phone*

Date of Birth*

Sex*

Male

Female

Other

Business Name

Business Phone

Driver's License Number*

Province*

Expiry*

License Type*

Driver Qualifications*

Please list all previous performance driving experience and accreditation. The information provided will support your application being approved by ORRA 27. Applications with insufficient information will be declined.

Applicant's Declaration

I declare the information above is accurate and, upon issuance of any ORRA licence, I agree to abide by and observe the applicable rules as outlined in the ORRA Rules & Regulations document and any other applicable regulations under penalty of Suspension or Revocation at ORRA’s sole discretion.
I declare that the information regarding my present state of health, as given to physician is correct
I agree to be re-examined as follows:
1. Upon the expiration of my current medical as required by the current competition rules
2. Following any signicant illness, injury or hospitalization.
I give permission to any hospital, institution or physician to furnish my medical information to ORRA

Applicant's Signature*

Date*

Signature of Parent/Guardian (if under 18 years old)

Date

Please note, submission and payment of an application does not guarantee the applicant will be issued a license. Applicants must meet all qualifications prior to being granted a license. Applicants that do not meet the requirements for their respective license will be declined and the application fees will be returned.

Total

Credit Card

Card Details

Cardholder Name

License Application

Applicant Info

Applicant's Medical Self-Declaration

Applicant's Declaration