Ignition Interlock Program Application

Personal Information

First Name(Required)

Last Name(Required)

Phone(Required)

State(Required)

Email(Required)

Violation #(Required)

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Year

VIN #

*By submitting this form and signing up for texts, you consent to receive customer care and marketing text messages (e.g. promos, appointment reminders) from LifeSafer Ignition Interlock at the number provided, including messages sent by autodialer. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe link (where available). Reply HELP for help. Privacy Policy & Terms of Use.

*By submitting this form, you agree and consent for LifeSafer and its affiliates to use automated technology, including emails, calls, texts, and prerecorded messages, to contact you at the information provided. No purchase necessary; message and data rates may apply.

Note: Upon receipt of this form, a state-approved provider will contact the applicant by phone to complete the sign-up process. Receipt of this form does not guarantee completion of state IID requirements. Monthly service fees, installation fees, and taxes may apply.

More IID Information: 800-634-3077