Authority to Speak Authorisation Form

Participants Name *

First

Last

Date of Birth *

Drivers Licence Number *

Participants Email *

Authorised Person *

First

Last

Authorised Person's Date of Birth *

Authorised Person's Phone Number *

Authorised Person's relationship to Participant *

ie. Parent, Sibling, Domestic partner, Friend, power of attorney

Authority to Speak *

I, the abovementioned participant, confirm that by submitting this form I am providing the abovementioned authorised person full and complete authority to discuss my Alcohol Interlock Program with Guardian Interlock Systems Australasia Pty Ltd. I understand that this includes access to program event logs, financial transactions, personal details, vehicle details and any other information provided to Guardian Interlock Systems.

Submission Date *