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100K Club Entry Form
100k Club Entry Form
1
Personal Details
2
Vehicle & Tyre Details
Personal Details
First Name
(Required)
Last Name
(Required)
Phone
(Required)
Email
(Required)
Street/Unit Number
(Required)
Street Name
(Required)
Suburb
(Required)
State
(Required)
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Post Code
(Required)
Vehicle & Tyre Details
REGO
(Required)
Vehicle Make And Model
(Required)
Tyre Purchased
(Required)
Select a Pattern
ROAD+TRAIL AT
STRONGHOLD AT
RUGGED TREK
AT3 LT
STT PRO
AT3 XLT
S/T MAXX
ATT
AT3 4S
Pro Control
LTZ PRO
CTT
EVOLUTION C5
Journey Details
(Required)
Photos of tyres
(Required)
Accepted file types: pdf, jpg, png, Max. file size: 10 MB.
Photos of you
(Required)
Accepted file types: pdf, jpg, png, Max. file size: 10 MB.
Date of Purchase
(Required)
MM slash DD slash YYYY
PLACE OF PURCHASE
(Required)
I GIVE PERMISSION FOR IMAGES IN WHICH I, AND/OR MY VEHICLE OR PASSENGER, APPEAR TO BE USED BY COOPER TIRES FOR PUBLICATIONS AND ONLINE ACTIVITIES.*
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