Intoxalock Ignition Interlock Device Information Form

Please complete the form to enroll in the ignition interlock process with one of the state-approved providers, Intoxalock. Once complete, click SUBMIT at the bottom of the page. For more information, please call 866-604-5247 for immediate assistance.

First Name

Last Name

Phone

Offense #

Zip Code

Violation Date

Violation County

Vehicle Make

Vehicle Year

Vehicle Model

VIN #

TCPA

By clicking the button, you consent to and its affiliate Breathe Easy Insurance Solutions, LLC calling and texting at the telephone number provided, without regard to the time of day, to encourage the purchase or lease of DUI-related products and services, including through the use of automated technology, artificial voice and/or pre-recorded means. Consent is not a condition of purchase. For California residents, click here.

NOTE: Upon receipt of form, state-approved provider will contact applicant via phone for further processing. Receipt of this form does not guarantee fulfillment of obligation to install an ignition interlock device. Monthly service fees, installation fees and taxes may apply.