Foreword

The removal of your interlock is your decision. If you have a removal letter please upload it. If you do not have a removal letter your device shall be removed as requested however noting and acknowledging the following conditions:

You cannot legally drive without an interlock until you receive a completion notice. Removing the device will be at your own risk.
Removing the device prematurely, and needing to re-install due to non-program completion may incur fees for the re-installation and further removal when required.
Any days that the device is not in your vehicle, your program is on HOLD, and days toward your program will not be counted.
If you drive with an interlock condition on your licence, without the interlock in your car, you risk a significant fine and may also need to re-start the program.

Participant Information

First Name *

Last Name *

Email Address *

Mobile Phone Number *

Enter today's date. *

Select State *

Drives License Number (CRN) *

Vehicle Details

Make *

Model *

VRN *

Removal Date and Type

Removal Date *

Removal Type *

Program Completed Eligible for Removal

By signing below, Participant hereby confirms their eligibility for the removal of the interlock on the previously selected “Removal Date”. Participant acknowledges that any outstanding fee’s are due and payable on or before the removal date. Participant acknowledges that there are no outstanding disqualification, suspension or unsatisfactory performance which may extend the period of the interlock program beyond the removal date. Participant releases Service Provider and Authorized Service Agent, along with their employees, officers and directors, from any and all actions, causes of action, claims and demands relating to the removal of the interlock.

Early Termination

By signing below, Participant hereby terminates the Service Agreement entered into between Participant and Service Provider pursuant Para 8 of its terms and conditions. The participant is aware that this constitutes early termination of the Service Agreement, and that the Removal Fee and Early Termination Fee are due and payable. Participant acknowledges that early termination will be reported to the Administering Authority and may result in loss of driving privileges. Participant releases Service Provider and Authorized Service Agent, along with their employees, officers and directors, from any and all actions, causes of action, claims and demands relating to such early termination. Participant also acknowledges the Foreword as per above.

Privacy Statement

Persuant to the Service Agreement, Affordable Interlock Systems (AIS) collects your personal information to provide you services. 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

Signature Block *

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