Smart start Ignition Interlock

Separating Drinking From Driving!

   Ignition Interlock Devices

     Toll Free 866-747-8278

            24 Hour Service

Schedule an Installation
Install Information Form

Personal Information

Please fill out the following information so we can get all your paperwork ready and have it waiting at your appointment.
Name*

First
Last
Please enter middle initial in first name box
after first name.
Address*

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number

###		-
###		-
####
Email Address
No SPAM just for instructions, information, and
receipts.
Drivers License Number
Drivers License State Issued
County of Conviction
County/State
Date of Birth

MM		/
DD		/
YYYY
How did you hear about us?
Are you under probation? If so please list name
and number.
Probation Name
Probation Number
How long are you required to have interlock?
Convenient Appointment Day?
 Monday 
 Tuesday 
 Wednesday 
 Thursday 
 Friday 
 Saturday 
 Any 
We will try to get you options that fit closely
with your preferred time.
Convenient Appointiment time?
 AM 
 PM 
For specific Day/Hour availability, please enter
information below.

Vehicle Information

Information on the vehicle you want installed.
Make*
Model*
Year*
Tag / License Plate and state issued. (Ex. "WEX
933, KS)
VIN (Vehicle Identification Number)
Vehicle Color
Date you need installed by.

MM		/
DD		/
YYYY
Date your interlock restriction starts.

MM		/
DD		/
YYYY
Next of Kin

First
Last
Next of Kin Phone Number

###		-
###		-
####
Emergency Contact