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Application for Interlock Installation
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The information is used to generate your reporting ID and any necessary paperwork.
Call (866)694-6099 if you have any questions.
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Preferred Date/Time for installation
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Full Name
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Driver's license number (same as old number
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Date of Birth
MM
/
DD
/
YYYY
Email address
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Address
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Primary Phone #
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Alternate Phone #(or emergency contact)
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Ordered for Interlock Device by:
Court-Probation, Treatment court, Bond Condition, Other
State Driver's License program-1st offense
State Driver's License program-2 or more
Florida Diversion Program
Other:
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If court or diversion program, please list the name of the program or court, and contact information for your probation officer or the person you report to at that program:
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Attorney Name
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Substance Abuse Evaluator Name
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Time preference for download appointments(once every 30 or 60 days, depending on order)
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Vehicle Make
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Model
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Year
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Color
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Mileage
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VIN
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License Plate(if any)
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