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2025 ASA PERMANENT LICENCE APPLICATION FORM
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I am a: Mark all activities relevantAthleteCoachTechnical OfficialOffice Bearer
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Discipline: Mark all activities relavant
Track & Field
Road RunningOff-Road RunningRace Walking
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Demographics - SRSA RequirementBlackColouredIndianWhite
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Age category - SRSA RequirementSenior+JuniorHigh SchoolPrimary School
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Gender:MaleFemale Date of Birth (YYYY-MM-DD)--
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Title (Mr/Ms/Dr/ect.)Initials
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Surname
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First Name
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Type of Identification DocumentID Book/CardBirth Certificate PassportRefugee Permit
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Number
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ASA Province
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2024 Licence Number 2025 Licence Number
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Club Name (in full)
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Residential Address - Domicilium Rule
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Code
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Postal Address - Domicilium Rule
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Code
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Tel/Cell phone number 1st 2nd
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Email address
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Occupation
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Next of Kin
Name
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Tel/Cell phone number1st 2nd
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Date: ……………………………………
Signature applicant: ………………………………………………………………
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Date: ……………………………………
Signature of Parent/Guardian (Younger than 18yrs): ……………………………………….
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Club: I confirm that the above information is correct; the athlete is registered to no other club; and domicile is correct.
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Date: ……………………………………
Signature of Club Representative: …………………………………………………………
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Province: I confirm that the club is affilliated to the province; and the domicile of the club and application is correct.
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Date: ……………………………………
Signature and stamp of the Province: …………………………………………………..
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