JAMAICA AUTOMOBILE ASSOCIATION
NEW MEMBER FORM - FIDELITY MOTORS
First Name
*
First Name
Middle Name
Last Name
*
Surname
TRN Number
*
TRN/ Drivers License Number
Gender
Please Select
Male
Female
N/A
Date of Birth
*
-
Day
-
Month
Year
DOB
Mailing Address
Street Address
Street Address Line 2
City
Parish
Postal Code/ P.O.
Primary Telephone Number
*
Please enter a valid phone number.
Alternative Telephone Number
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Telephone Number
Please enter a valid telephone number.
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VEHICLE INFORMATION
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
Plate Number
*
Licence Plate of Vehicle
Drivers Licence Expiration Date
-
Day
-
Month
Year
Drivers Licence Exp
Registration Expiration Date
*
-
Day
-
Month
Year
Registration Exp
Fitness Expiration Date
*
-
Day
-
Month
Year
Fitness Exp
Insurance Company
Policy Type
Comprehensive
Third Party
Insurance Expiration Date
-
Day
-
Month
Year
Fitness Exp
Card Delivery/Pick-Up
Please Select
Fidelity Dealership (Hanover Street)
JAA Office
Deliver to Mailing Address
Choose a preferred mode to receive the card
Submission Information
Membership Period
*
Please Select
1 Year
3 Years (X-Trail only)
Name of Sales Agent
First Name
Last Name
Submitted by
example@example.com
Submitted by:
*
Complete this box only if the person submitting form is not sales agent
Submit
Should be Empty: