Participant Information

First Name *

Last Name *

Enter Your Address *

City / Town / Suburb *

Select Your Home State *

Postcode *

Email Address *

Enter Mobile Phone Number *Example +61412345678

Which State Interlock Program Are You Participating In? *

Program Type *

Have You Ever Had an Interlock? *

Are You Hearing Impaired? *

Interlock History

Is Your Vehicle Currently Fitted with an Interlock? *

Time remaining in program (days)

Jurisdiction for Existing Interlock *

Existing Interlock Provider *

Jurisdiction for Past Interlock *

Past Interlock Provider *

Centrelink Details (If Applicable)

Centrelink - CRN Type *

Centrelink - CRN *

Centrelink Card Expiry Date

Financial Assistance (if applicable)

Have you applied or are you planning to apply for Financial Assistance? *QLD Participants contact Transport for Main Roads 132380 NSW Participants contact The Salvation Army 02 8878 0151

Has Financial Assistance been approved?Where you have answered "Yes" to approval you will be required to provide evidence to be eligible for the Financial Assistance fee.

Are you required to make a Contribution towards the installation of the interlock?

How much is the Contribution Amount requested from The Salvation Army?

Upload Financial Assistance Letter/Certificate

Browse

Where Financial Assistance approval has been granted please upload your letter or certificate.

Vehicle Details

Are You The Registered Vehicle Owner *

Vehicle Year *

Vehicle Make *

Vehicle Model *

Enter "Other" Vehicle Make *

Enter "Other" Vehicle Model *

Ignition/Vehicle Type *

Engine Type *

What is the Registration Number?

Type

Acknowledgment

I acknowledge that the quoted price shall be based on the vehicle details provided in the quotation request form. In the event of a discrepancy where a different vehicle is presented during installation, Affordable Interlock Systems (AIS) retains the prerogative to decline installation, issue a revised quote, or negotiate an adjustment to the payment amount due on the day of installation.

*

I hereby authorize Affordable Interlock Systems to contact my previous provider on my behalf to verify that the interlock device has been removed and returned, and to confirm whether any outstanding fees remain. *

I acknowledge that if i fail to provide evidence of Financial Assistance approval, the applicable fees will be adjusted accordingly. *

Privacy Statement

Affordable Interlock Systems (AIS) collects your personal information to provide you with a quotation. Quotation information will be used by AIS and where relevant, may be shared with the applicable jurisdiction as a requirement by law. Your personal information will not be used for a further purpose or disclosed to a third party without consent unless authorised to required to by law. Further information about our privacy handling practices can be accessed here

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03Jul2024 V1.0