Affordable Interlocks Payment Portal

Payment From

Is the Cardholder the Participant in the Program? *

First Name *

Last Name *

Plate Number *

Payment Amount *

By ticking this box, as the participant, you expressly authorise this one-off payment for an interlock related expense. Such as installation, rental, code, removal, admin fee, replacement fee. This authorisation is limited to this specific transaction and shall not be construed as consent for any subsequent payments without the cardholder’s prior written approval. *

By ticking this box, you expressly authorise this one-off payment for the interlock installation or rental on behalf of the above-named Participant. This authorisation is limited to this specific transaction and shall not be construed as consent for any subsequent payments without the cardholder’s prior written approval. *

Card Holder First Name *

Card Holder Last Name *

Registration Number *

Amount *

Save and Complete Later

Affordable Interlock Systems Pty Ltd

1-800-252-656

AIS-NET-O-006

02MAR2021 V1.0