Form PS31205 "Ignition Interlock Device Program Employment Exemption Application" - Minnesota

What Is Form PS31205?

This is a legal form that was released by the Minnesota Department of Public Safety - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PS31205 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS31205 "Ignition Interlock Device Program Employment Exemption Application" - Minnesota

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M
D
P
S
INNESOTA
EPARTMENT OF
UBLIC
AFETY
Ignition Interlock Device Program Employment
Exemption Application
Application Packet
Please read the following instructions carefully.
There are two parts to the Ignition Interlock Device Program Employment Exemption Application.
 Page 2 must be filled out by the ignition interlock participant.
 Page 3 must be filled out by the participant’s employer.
This form can be faxed to (651) 797-1299. You may also bring this form to any Driver Exam Station
(Visit the
DVS Website
for all Office Locations) or mail this form to Driver and Vehicle Services, Ignition
Interlock Unit, 445 Minnesota Street, Suite 177, St. Paul, Minnesota 55101. For questions, contact DVS
at (651) 296-2948 or visit dvs.dps.mn.gov.
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota Statute.
If you do not provide this information, DPS cannot approve an employment variance for the Ignition Interlock Device Program. Personal information (name and
address of individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31205-08
Page 1 of 3
Rev. 5/2017
M
D
P
S
INNESOTA
EPARTMENT OF
UBLIC
AFETY
Ignition Interlock Device Program Employment
Exemption Application
Application Packet
Please read the following instructions carefully.
There are two parts to the Ignition Interlock Device Program Employment Exemption Application.
 Page 2 must be filled out by the ignition interlock participant.
 Page 3 must be filled out by the participant’s employer.
This form can be faxed to (651) 797-1299. You may also bring this form to any Driver Exam Station
(Visit the
DVS Website
for all Office Locations) or mail this form to Driver and Vehicle Services, Ignition
Interlock Unit, 445 Minnesota Street, Suite 177, St. Paul, Minnesota 55101. For questions, contact DVS
at (651) 296-2948 or visit dvs.dps.mn.gov.
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota Statute.
If you do not provide this information, DPS cannot approve an employment variance for the Ignition Interlock Device Program. Personal information (name and
address of individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31205-08
Page 1 of 3
Rev. 5/2017
Minnesota Ignition Interlock Device Program
Employment Exemption
EMPLOYEE SECTION (to be filled out by the ignition interlock participant)
Driver’s License Number
State of Issue
____________________________________________________________________________________________________________
First Name
Middle Name
Last Name
____________________________________________________________________________________________________________
Address
City/State/Zip
________________________
____________________________________________
________________________________
Phone Number
Email Address
Date of Birth
On the lines below, list your occupation and job duties. If more space is needed, please attach a separate piece of paper.
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
1.
I understand that if I am granted an employment exemption, I will still be required to
_________________________
install the ignition interlock device on another vehicle.
Signature
2.
I understand that the employment exemption is only valid for operating a company
_________________________
vehicle for business purposes and not for personal use.
Signature
3.
If my employment changes, I will notify Driver and Vehicle Services in writing within
_________________________
15 days.
Signature
4.
I certify that I am not self-employed (Minnesota Rule 7503.1775).
_________________________
Signature
5.
I certify that I do not own or partially own the business for which I am applying for an
_________________________
employment exemption (Minnesota Rule 7503.1775).
Signature
If granted an employment variance, you must keep it with you while driving. The variance is effective for 1 year. You must reapply
annually.
I verify the information on this document is truthful and accurate. I understand that any false information provided may result in
termination of my participation in the Minnesota Ignition Interlock Device Program.
_________________________________________________________________________________________________
Signature
Date
Witnessed by:
Subscribed and sworn to before me this day of _______ 20 _____
NOTARY PUBLIC_______________________________________
COUNTY_____________________________________________
MY COMMISSION
EXPIRES_____________________________________
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota Statute.
If you do not provide this information, DPS cannot approve an employment variance for the Ignition Interlock Device Program. Personal information (name and
address of individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31205-08
Page 2 of 3
Rev. 5/2017
Minnesota Ignition Interlock Device Program
Employment Exemption
EMPLOYER SECTION (to be filled out by the applicant’s employer)
Your employee is enrolled in the Minnesota Ignition Interlock Device Program (Program). As a participant in the Program, your
employee is required to only drive vehicles equipped with an ignition interlock device. Per Minnesota Statute 171.306 subdivision
4(b), a participant may drive an employer-owned vehicle without an ignition interlock device as long as the employer consents.
Employer Consent
____________________________________________________________________________________________________________
Name of Employee and Employee’s Driver’s License Number
____________________________________________________________________________________________________________
Name of Employer/Company
____________________________________________________________________________________________________________
Employer/Company Address
City/State/Zip
1.
Is this employee an owner or partial owner of the business for which the employee is
applying for the employment exemption (Minnesota Rule 7503.1775)?
Yes
No
2.
Does the employee need to drive the company vehicle to and from their home to work?
Yes
No
3.
Does the employee need to drive the company vehicle on-the-job for employment
purposes?
Yes
No
4.
Will the employee be using the company-owned vehicle for personal use?
Yes
No
On the lines below, list the employee’s job duties that require the use of the company vehicle. If more space is needed, please attach a
separate piece of paper.
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I hereby certify that the above named employee’s job responsibilities require him/her to operate a company vehicle. I am aware that
he/she is currently restricted to drive vehicles equipped with an ignition interlock device. I further understand that this employment
exemption is only valid for operating a company vehicle for business purposes and not for personal use.
_________________________________________________________________________________________________
Signature of Authorized Representative
Date
_________________________________________________________________________________________________
Print Name
Phone Number
Title
Witnessed by:
Subscribed and sworn to before me this day of _______ 20 _____
NOTARY PUBLIC_______________________________________
COUNTY_____________________________________________
MY COMMISSION
EXPIRES_____________________________________
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota Statute.
If you do not provide this information, DPS cannot approve an employment variance for the Ignition Interlock Device Program. Personal information (name and
address of individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31205-08
Page 3 of 3
Rev. 5/2017
Page of 3