Participant Information

First Name *

Last Name *

Email Address *

Best Phone Number *

Vehicle Registration Number *

Drives License Number (CRN) *

Participant Authorisation

I, as the participant, hereby authorise the nominated person, to enquire and act on my behalf in all matters pertaining to the Affordable Interlock Systems interlock installation, interlock program and financial payments related to the program.

This authorisation shall remain valid until expressly revoked by me, the participant, in writing.

I understand that by granting this authorisation, I am giving the nominated person the authority to make decisions, take actions on my behalf, make payments and I agree to indemnify and hold harmless the nominated person from any liabilities arising from actions taken in good faith under this authorisation.

However, should the nominated person make any payment and cancel such payment, the participant, being the undersigned, hereby agrees to accept full responsibility and shall remain liable for all payments due, including any associated late fees or bank charges.

Participant Signed Authorisation

Participant Signature Block *

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Nominated Person

Nominated First Name *

Nominated Last Name *

Nominated Email Address *

Nominated Best Phone Number *

Nominated Drivers License Number (CRN)

Nominated Person Authorisation

I, as the nominated person, hereby acknowledge and accept the authorization granted to me by the participant to enquire and act on my behalf in all matters pertaining to the Affordable Interlock Systems interlock installation, interlock program and financial payments related to the program.

I understand the responsibilities entrusted to me under this authorization, and I agree to act in accordance with the wishes and best interests of the participant to the best of my abilities.

I acknowledge that this acceptance is subject to the laws of Australia, and I commit to fulfilling my duties in compliance with all applicable legal requirements.

Nominated Person Signed Authorisation

Nominated Person Signature Block *

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