Nasa Competition License Application Form printable pdf download

NASA COMPETITION LICENSE APPLICATION

Please complete the appropriate sections below and submit to the NASA National Office

Membership Number ___________________

Local NASA Chapter ___________________________

Name________________________________

Phone ________________________________

Street Address ________________________________

City ________________________________

State _____________ Zip _________________

Email________________________________

First Time NASA Competition License

Rookie Permit or Provisional is attached.

Medical Evaluation is attached. Expiration Date: _______

Required medical evaluation schedule: Racers under 40 – every 5 years; 40-49 – every 3 years, 50-70 every 2 years, 70+- every year

EKG Tracing printout if over the age of 45

A copy of my state driver’s license is attached.

NASA Competition License Renewal

Medical Evaluation is attached. Expiration Date: _______

Medical Evaluation is on file. Expiration Date: _______

Required medical evaluation schedule: Racers under 40 – every 5 years; 40-49 – every 3 years, 50-70 every 2 years, 70+- every year

EKG Tracing printout if over the age of 45 if not previously submitted to NASA

NASA Competition License “School Requirement” Waiver

– requires license from another sanctioning body

I have been licensed by another sanctioning body.

Sanctioning Body: ________________________ License Exp.: _______

Copy of Competition License is attached.

Medical Evaluation is attached. Expiration Date: _______

A copy of my state driver’s license is attached.

Brief Driver / Race Resume

Please submit the required documents with a credit card number ($85 Seasonal License Fee)

Submit using one of the options below:

1. Upload to your profile:

2. Email to:

3. Fax: 510-277-0657

4. Mail to: NASA-Licensing, P.O. Box 2366, Napa Valley, CA 94558

VISA / MasterCard only # __________ - __________ - __________ - __________ Expires _____________

Credit Card CVV2 code (REQUIRED) ________ [This is the three digit code on the back of your card]

Billing address (if different) _____________________________________________________________

Billing City _______________________________ State ________ Zip __________________________

Please give me a membership / renewal for $45 using the credit card above (circle):

yes

Driver Signature __________________________________________

Date ____________________

Nasa Competition License Application Form