• Required fields are marked with an asterisk (*)

    • Business Details

    • Company Name*

    • Vehicle Details

    • Number plate of the vehicle listed for Roadservice*

    • Make*

    • Model*

    • Nominee Details

    • Title: Miss / Mrs / Ms / Mr / etc.*

    • First Name*

    • Last name*

    • Date of birth*

      (D/M/Y)

    • Postal Address*

    • Street Address (leave blank if same as postal address)

    • Suburb*

    • City*

    • Contact Phone Number*

    • Mobile Phone Number*

    • Email address*

    • I understand that the information provided by me may be used by the NZAA for administrative purposes and for the purpose of providing me with information relating to products and services from time to time. For this purpose the NZAA includes itself and any division, subsidiary, third party under contract, or joint venture companies.*