Form 2008 IID APP "Interlock Program Application Form" - Delaware

Form 2008 IID APP is a Delaware Department of Transportation form also known as the "Interlock Program Application Form". The latest edition of the form was released in March 1, 2017 and is available for digital filing.

Download a PDF version of the Form 2008 IID APP down below or find it on Delaware Department of Transportation Forms website.

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Download Form 2008 IID APP "Interlock Program Application Form" - Delaware

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STATE OF DELAWARE
DEPARTMENT OF TRANSPORTATION- DIVISION OF MOTOR VEHICLES
INTERLOCK PROGRAM APPLICATION
Application Date: _______ _
APPLICANT INFORMATION
Date of Birth
Name
Expire Date:
DE Driver License #
Address
State
Zip
Phone:
City
Night
Day
VEHICLE INFORMATION:
A separate form must be completed for each vehicle on which the Ignition Interlock Device is to be Installed.
Vehicle Identification Number
(VIN):
Year
Make
J Model
J
Expiration Date
Vehicle Registration (Tag) Number
I
(ATTACH COPY OF REGISTRATION CARD)
Owners Name
Co-Owners Name
State
Zip
City
Address if different than above
This is to certify that I/we give permission for the applicant to drive the above listed
Vehicle and to have the Ignition Interlock Device installed on the vehicle.
Signature of Vehicle Owner
Signature of Co-owner
Date
Date
OMV Witness or Notary Signature
Date
DMV Witness or Notary Signature
Date
The signature(s) of all vehicle owners must be signed on this application.
Proof of insurance MUST be shown at time application is completed and copy attached to application.
A letter from the insurance agent is needed if the applicant's name is not on the policy that the applicant will be
insured on the Policy and is authorized to drive the above listed vehicle.
IID SERVICE PROVIDER SELECTION - REQUIRED
Please select one of the service providers listed below to provide your interlock devic e
service. A
lications will NOT be rocessed until a service rovider is selected.
DRAEGER
LIFESAFER INTERLOCK
1-800-332-6858 - Please contact IID Service Provider for
1-800-374-5760 - Please contact IID Service Provider for
a
licable fees and costs.
a
licable fees and costs.
I certify that I have met the requirements specified in 21 Del. C. §4177 G including enrollment in an alcohol education
and/or treatment program. I further certify that I have received a copy of the Conditions of Participation specified in 21
Del. C. § 4177 G (f). I will abide by these conditions and understand that failure to abide by these conditions will result
in termination from the program and loss of all driving privileges for the complete duration of the revocation period.
Signature of Applicant
Date
DMV Witness or Notary Signature
Date
STAFF INSTRUCTIONS: Submit this completed application along with valid insurance documentation
and current registration card to the Dover Administration Office to be approved for installation of the
Ignition Interlock Device. ALL signatures must be notarized or witnessed by a Division staff member.
D
D
OFFICE USE ONLY: Program: OD PC PT TH Completion Date: _/_/_ CBR:
Needed
Approved
Documenl No 45-01-40-96-10-01
Form #:2008 IID APP (3/2017)
-
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STATE OF DELAWARE
DEPARTMENT OF TRANSPORTATION- DIVISION OF MOTOR VEHICLES
INTERLOCK PROGRAM APPLICATION
Application Date: _______ _
APPLICANT INFORMATION
Date of Birth
Name
Expire Date:
DE Driver License #
Address
State
Zip
Phone:
City
Night
Day
VEHICLE INFORMATION:
A separate form must be completed for each vehicle on which the Ignition Interlock Device is to be Installed.
Vehicle Identification Number
(VIN):
Year
Make
J Model
J
Expiration Date
Vehicle Registration (Tag) Number
I
(ATTACH COPY OF REGISTRATION CARD)
Owners Name
Co-Owners Name
State
Zip
City
Address if different than above
This is to certify that I/we give permission for the applicant to drive the above listed
Vehicle and to have the Ignition Interlock Device installed on the vehicle.
Signature of Vehicle Owner
Signature of Co-owner
Date
Date
OMV Witness or Notary Signature
Date
DMV Witness or Notary Signature
Date
The signature(s) of all vehicle owners must be signed on this application.
Proof of insurance MUST be shown at time application is completed and copy attached to application.
A letter from the insurance agent is needed if the applicant's name is not on the policy that the applicant will be
insured on the Policy and is authorized to drive the above listed vehicle.
IID SERVICE PROVIDER SELECTION - REQUIRED
Please select one of the service providers listed below to provide your interlock devic e
service. A
lications will NOT be rocessed until a service rovider is selected.
DRAEGER
LIFESAFER INTERLOCK
1-800-332-6858 - Please contact IID Service Provider for
1-800-374-5760 - Please contact IID Service Provider for
a
licable fees and costs.
a
licable fees and costs.
I certify that I have met the requirements specified in 21 Del. C. §4177 G including enrollment in an alcohol education
and/or treatment program. I further certify that I have received a copy of the Conditions of Participation specified in 21
Del. C. § 4177 G (f). I will abide by these conditions and understand that failure to abide by these conditions will result
in termination from the program and loss of all driving privileges for the complete duration of the revocation period.
Signature of Applicant
Date
DMV Witness or Notary Signature
Date
STAFF INSTRUCTIONS: Submit this completed application along with valid insurance documentation
and current registration card to the Dover Administration Office to be approved for installation of the
Ignition Interlock Device. ALL signatures must be notarized or witnessed by a Division staff member.
D
D
OFFICE USE ONLY: Program: OD PC PT TH Completion Date: _/_/_ CBR:
Needed
Approved
Documenl No 45-01-40-96-10-01
Form #:2008 IID APP (3/2017)
IGNITION INTERLOCK PROGRAM
Participant Requirements
The Ignition Interlock Device (110) Program is authorized by 21 Del. C. §4177 G. The following are conditions of the
program as specified in 21 Del. C. §4177 G (f)(2). Each offender is required to abide by these conditions through the
duration of the program.
A offender shall lose the privilege of having a Offender IID license for failure to comply with any of the following:
1.
The offender shall abide by the terms of the offender's lease with the seNice provider as approved by the Division
of Motor Vehicles.
2.
The offender shall comply with Division of Motor Vehicle regulations concerning 110 license restrictions.
3.
The offender shall not attempt, nor allow or cause an attempt to bypass, tamper with, disable or remove the 110 or
its wires in connection.
The offender shall not operate a vehicle without an approved device, or possessing a registration card and a
4.
offender IID license which complies with subsection (f) of this section.
The offender shall not violate any section of this title relating to the use, possession or consumption of alcohol or
5.
intoxicating substances;
6.
The offender shall accumulate no more than 5 points per year while participating in the program.
7.
The offender shall continue to meet all eligibility criteria identified in subsection (f) (1) of this section.
8.
The offender shall provide satisfactory proof to the Division of Motor Vehicles that an approved IID has been
installed.
9.
The offender shall not fail to or refuse to take random re-test provided by the device.
10.
The offender shall keep scheduled appointments with the Division and the service provider.
11.
The offender shall be driven to the service provider by a licensed driver for installation of the IID equipment.
12.
The offender shall not cause nor allow another individual to bypass or attempt to bypass the device.
13.
The offender shall not fail to pay any and all fines whatsoever assessed during participation in the program
pursuant to this title.
14.
The offender shall successfully complete the course of instruction and/or program of rehabilitation.
15.
The offender shall comply with any participation regulations implemented by the Division of Motor Vehicles
pursuant to this paragraph.
16.
The offender will receive written confirmation for approval of the ignition interlock device. The device
shall not be installed without prior approval from this Division.
Non-compliance with the above listed requirements may disqualify offender from eligibility for the IID license. The
offender will be required to maintain the Ignition Interlock Device on all vehicle(s) registered in the name of the offender
for the balance of the revocation period.
EXTENSION OF REVOCATION PERIOD FOR VIOLATION OF PROGRAM REQUIREMENTS
The revocation period will be extended 2 months for any combination of three (3) of the below listed requirements.
The revocation period will be extended 4 months for any combination of five (5) of the below listed requirements.
The revocation period will be extended 6 months for any combination of eight (8) of the below listed requirements.
The revocation period will be extended one (1) additional month for each violation of the below listed requirements over 8.
Each SAC reading of .05 or above
Each missed monitoring appointment
Start up violation; IE lock-out failure
Tampering with or bypassing the interlock system
Running Retest Violation
Intentional circumvention of the interlock system or program
requirements
Each state has different laws that may further restrict or even prohibit IID licenses when a driver's license status is
revoked. It is your responsibility as the holder of an IID license, not the Delaware OMV, to contact the OMV or law
enforcement agency in other states to ensure your ability to operate a motor vehicle with an 110 license in other
jurisdictions.
I certify that I have read the Conditions of Participation above, specified in 21 Del. C. § 4177 G (f)(2). I will abide by
these conditions and understand that failure to abide by these conditions will result in termination from the program
and loss of all driving privileges for the complete duration of the revocation period.
Signature of Offender
Date
Signature of Division of Motor Vehicles Personnel
Date
Form #:2008 IID APP (3/2017)
Document
No.
45-01-40-96-10-01
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