Honda Riders Club of Australia - Rider Assist Application

Honda Rider Assist - you'll never ride alone!

Honda Rider Assist Application Form

* Denotes required Field
 

$69.00

Honda Rider Assist Gold

$119.00

Honda Rider Assist Platinum

Prices shown above are for a 12 month period and include GST.
Honda Rider Assist is only valid after payment has been received and cleared.
 

HRCA Membership Number if applicable

 

Personal Details:

Email Address:

*

Surname:
*

First Name:

*

Address:

Town:

State:

Post Code:

Phone:

Business:
 

Motorcycle Particulars:

Model:

Year:

Registration:

Kilometer's

Colour:

VIN :   

17 Digit VIN is located on Motorcycle Head Stem
 

Payment Details:
American Express Bankcard Mastercard
Visa Check Money Order

Name on Card

Card Number:

Expiry Date
 
 
Cheques to be made to: Honda Rider Assist

All entitlements & Prices are valid as of the 1/7/2005 and are subject to change without notice. The services are provided on behalf of the Honda Riders Club of Australia by International SOS.

Thank You and welcome to Honda Rider Assist

Please allow 1 working day for a reply

 
Benefits and Conditions
Honda Rider Assist Limitations and Exclusions