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Installation Request

Enter your first name *
Enter your last name *
Enter your street address *
Enter City, State and Zip Code *
Enter email address
Enter Telephone Number *
How many DUIs have you had in your lifetime?
How long ago was your license suspended?
Which State and County gave you your last DUI conviction?
Please describe the vehicle you will bring to your installation appointment. Include year, make, and model
Have you completed your 4 day (20 hour) DUI Risk Reduction class?
Do you have an enrollment certificate from the clinical treatment program?
Do you have a completion certificate from the clinical treatment program?
Do you have a Certificate of Eligibility from the county where you received your last DUI?
How soon would you like to have your interlock device installed?
Enter any other information you would like to share.