IGNITION INTERLOCK DEVICE INFORMATION FORM

Please complete the form to enroll in the ignition interlock process with one of the state-approved providers, Intoxalock. Once complete, click SUBMIT at the bottom of the page. For more information, please call (866) 604-5247 for immediate assistance.

PERSONAL INFORMATION

First Name:

Last Name:

Phone:

Zip Code:

Email:

VIOLATION DATE: MM/DD/YYYY:

OFFENSE #:

VIOLATION COUNTY:

VEHICLE

MAKE:

MODEL:

YEAR:

VIN #:

OFFICE USE ONLY

IDENTIFICATION #:

REPORTING AUTHORITY:

DATE: MM/DD/YYYY

SIGNATURE:

NOTE: Upon receipt of form, state-approved provider will contact applicant via phone for further processing. Receipt of this form does not guarantee fulfillment of obligation to install an ignition interlock device. Monthly service fees, installation fees and taxes may apply.

IGNITION INTERLOCK DEVICE INFORMATION FORM

IID Info Line: (866) 604-5247

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