Participant Information

First Name *

Last Name *

Are You Hearing Impaired? *

Enter Your Address *

City / Town / Suburb *

Select Your State *

Postcode *

Email Address *

Enter Mobile Phone Number *

Is the Vehicle fitted with an Interlock? *

Have You Ever Had an Interlock? *

Who is Your Current Provider? *

Who Was Your Previous Provider? *

Time Remaining in Program *

Centrelink Details (If Applicable)

Centrelink - CRN Type *

Centrelink - CRN

Centrelink Card Expiry Date

Vehicle Details

Are You The Registered Vehicle Owner *

Make *

What is the Registration Number?

Model *

Year *

Ignition Type *

Engine Type *

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.

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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