IMMEDIATE ROADSIDE ASSISTANCE 6748 9911
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"*" indicates required fields 1Personal Details2Residential Address3Driving License4Membership Registration Type REGISTRATION FORM Personal DetailsHiddenRegistration Page Salutation* DR MR MRS MS MDM Gender* Male Female Full Name as Per NRIC* Occupation*- No Selected -Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherLast 3 digits + checksum of NRIC/FIN no.* (E.g. "567A" from the full NRIC number “S1234567A”)Date of Birth* DD dash MM dash YYYY Nationality*- Not Selected -AlbanianAlgerianAmericanAndorranAngolanAntiguansArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBhutaneseBolivianBosnianBrazilianBritishBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdianCentral AfricanChadianChileanChineseColombianComoranCongoleseCosta RicanCroatCubanCypriotCzechDanishDjiboutiDominicanDutchEast TimoreseEcuadoreanEgyptianEmirianEquatorial GuineanEritreanEstonianEthiopianFijianFilipinoFinnFrenchGaboneseGambianGeorgianGermanGhanaianGreekGrenadianGuatemalanGuinea-BissauanGuineanGuyaneseHaitianHonduranHungarianIcelanderI-KiribatiIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtensteinerLithuanianLuxembourgerMacedonianMalagasyMalawianMalaysianMaldivanMalianMalteseMarshalleseMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMoroccanMosothoMotswanaMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNi-VanuatuNorth KoreanNorwegianOmaniPakistaniPalauanPanamanianPapua New GuineanParaguayanPeruvianPole or PolishPortugueseQatariRomanianRussianRwandanSaint LucianSalvadoranSamoanSan MarineseSao TomeanSaudi ArabianSenegaleseSerbianSeychelloisSierra LeoneanCHINASlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinamerSwaziSwedishSwissSyrianTadzhikTaiwaneseTanzanianThaiTogoleseTonganTrinidadianTunisianTurkishTurkmenTuvaluanUgandanUkrainianUzbekistaniVenezuelanVietnameseYemeniZambianZimbabweanHong KongerKoreanOthersSingaporeanRace*- Not Selected -AMERICANARABAUSTRALIANBOYANESEBRITISHBURMESECAUCASIANCEYLONESECHINESEDUTCHEURASIANEUROPEANFILIPINOGERMANHISPANICINDIANINDONESIANSJAPANESEJAVANESEKOREANMALAYMALAYALEENEW ZEALANDEROTHERSPAKISTANIPHILIPPINAPUNJABISCOTSIKHSRI LANKANSUBSECTTAIWANESETHAIVIETNAMESEEmail* Mobile Phone*✓ Valid number ✕ Invalid numberTelephone✓ Valid number ✕ Invalid numberWhat is your marital status?* Single Married Divorced Widowed REGISTRATION FORM Residential AddressPostal Code* ZIP / Postal Code Block/House No.* Street Name* Building Name Floor Level Unit No. Country*- Not Selected -AFGHANISTANALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUAARGENTINAARMENIAARUBAASCENSIONAUSTRALIAAUSTRALIAN EXTERNAL TERRITORIESAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBARBUDABELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIA & HERZEGOVINABOTSWANABRAZILBRITISH VIRGIN ISLANDSBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCANADACAPE VERDE ISLANDSCAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHATHAM ISLAND (NEW ZEALAND)CHILECHINA (MAINLAND)CHRISTMAS ISLANDCOCOS-KEELING ISLANDSCOLOMBIACOMOROSCONGOCONGO DEM. REP. OF (FORMER ZAIRE)COOK ISLANDSCOSTA RICACÔTE D'IVOIRE(IVORY COAST)CROATIACUBACUBA (GUANTANAMO BAY)CURAÇAOCYPRUSCZECH REPUBLICDENMARKDIEGO GARCIADJIBOUTIDOMINICADOMINICAN REPUBLICEAST TIMOREASTER ISLANDECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJI ISLANDSFINLANDFRANCEFRENCH ANTILLESFRENCH GUIANAFRENCH POLYNESIAGABONESE REPUBLICGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUANTANAMO BAYGUATEMALAGUINEAGUINEA-BISSAUGUYANAHAITIHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAINMARSAT (ATLANTIC OCEAN - EAST)INMARSAT (ATLANTIC OCEAN - WEST)INMARSAT (INDIAN OCEAN)INMARSAT (PACIFIC OCEAN)IRANIRAQIRELANDISRAELITALYJAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKOREA (NORTH)KOREA (SOUTH)KUWAITKYRGYZ REPUBLICLAOSLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA (FORMER YUGOSLAV REP OF.)MADAGASCARMALAWIMALAYSIAMALDIVESMALI REPUBLICMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTE ISLANDMEXICOMICRONESIA (FEDERAL STATES OF)MIDWAY ISLANDMOLDOVAMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEVISNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANAS ISLANDSNORWAYOMANPAKISTANPALAUPALESTINIAN SETTLEMENTSPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPOLANDPORTUGALPUERTO RICOQATARRÉUNION ISLANDROMANIARUSSIARWANDESE REPUBLICSAMOASAN MARINOSÃO TOMÉ AND PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLES REPUBLICSIERRA LEONESLOVAK REPUBLICSLOVENIASOLOMON ISLANDSSOMALI DEMOCRATIC REPUBLICSOUTH AFRICASPAINSRI LANKAST. HELENAST. KITTS/NEVISST. LUCIAST. PIERRE & MIQUELONST. VINCENT & GRENADINESSUDANSURINAMESWAZILANDSWEDENSWITZERLANDSYRIATAIWANTAJIKISTANTANZANIATHAILANDTIMOR LESTETOGOLESE REPUBLICTOKELAUTONGA ISLANDSTRINIDAD & TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATES OF AMERICAURUGUAYUS VIRGIN ISLANDSUZBEKISTANVANUATUVATICAN CITYVENEZUELAVIETNAMWAKE ISLANDWALLIS AND FUTUNA ISLANDSYEMENZAMBIAZANZIBARZIMBABWEEUROPEYUGOSLAVIAISTANBULUNKNOWNNAIROBISCOTLANDOTHERSSINGAPORE REGISTRATION FORM Driving LicenseDriving License No. Driving License Class22A2B33A44A4B5Driving License Expiry Date YYYY dash MM dash DD (Not applicable for Singaporeans)Car Details Registration No. Brand- Not Selected -ASTON MARTINAUDIBMWCHEVROLETCITROENDAIHATSUFERRARIFORDHONDAHYUNDAIJAGUARKIALEXUSMASERATIMAZDAMERCEDESMITSUBISHINISSANOTHERSPEUGEOTPORSCHERENAULTSAABSKODASUBARUTESLATOYOTAVOLKSWAGENVOLVOSUZUKIBUICKCADILLACHAFEIBentleyModel HiddenColour REGISTRATION FORM Membership Registration TypeI would like to apply for:* Social Term and Gift* Family New 1 year(s)1-YEAR @ $33 (Usual $40.10) No GIFT Family New 2 year(s)1-YEAR @ $63 (Usual $80.20) No GIFT Family New 3 year(s)1-YEAR @ $83 (Usual $120.30) No GIFT Term and Gift* Ordinary New 3 year(s)Receive Black & Decker Steam Mop worth $158.40 redemption from 28 Feb 23 at AA Centre Ordinary New 3 year(s)Black & Decker 2-in1 Cordless Vacuum Cleaner worth $219.30 redemption from 28 Feb 23 at AA Centre Ordinary New 2 year(s)FREE Verbatim Charger worth $85 REDEMPTION FROM 15 FEB 23 AT AA CENTRE Ordinary New 1 year(s)No Gift Term and Gift* Youth New 2 year(s)FREE Verbatim LED Desk Lamp worth $59 Redemption from 15 Feb 2022 Youth New 1 year(s)No Gift Term and Gift* Social New 1 year(s)No Gift Total Details of Principal MemberAA Membership No.* Applicant Relationship to Principal Member* Spouse Child below 21 years MEMBER-GET-MEMBER (MGM) PROGRAMME I have been referred by a friend who is a valid member.Referrer’s Membership No. (If applicable) Note: By providing the above information, you have agreed to be recommended by your referrer who may qualify for AA MGM Programme. Click here for the Terms and Conditions of the programme.terms and conditions* I have read and agreed to the terms and conditions.*service policy* I have read and agreed to the service policy.*Privacy Policy* I have read and agreed to the privacy policy.*HiddeneNets Txn Ref Hiddenmembership_expiry_date DD slash MM slash YYYY
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