Guardian Interlock Client Service Form and Service Agreement

Guardian Interlock Systems Pty Ltd requires a completed Client Service Form and Service Agreement for your upcoming Alcohol Interlock installation. Please complete the below and press the submit button. Please submit at least 2 days prior to your installation appointment. Please note that if this form is not provided you may experience delays on the day of installation. We appreciate your assistance with this matter.

State of Licence / Interlock Program *

CLIENT INFORMATION

Interlock Program Participant Name *

First

Last

Participant Address *

Address Line 1

City

State / Province / Region

Postal Code

Participant Mobile Number *

Participant Home Phone Number

Participant Email Address *

Participant Date of Birth *

Participant Driver Licence Number *

Participant Gender *

Do you wish to have your Concession Card reviewed for eligibility *

Please note all concession discount validity are check online with Services Australia after each service and discount will be charged back if found to be invalid. Rules apply to concession validity including maximum rate requirements in most states. Concession rules are set by each state government. Complete the link provided below after selecting Yes to have this information included on your account. Your concession card will need to be present at every service prior to the transaction commencing. We do not backdate concessions.

Interlock Program Duration *

This detail is provided on the documentation received from your state road authority. Please note that VIC and WA programs are always set at 6 months initially.

Interlock Installation State *

Please select the state where you are having your install done

Do you have a confirmed Installation Appointment Date *

Next of Kin / Alternate Contact Full Name *

Next of Kin is the person you would consider your emergency contact eg. family member or close friend

Next of Kin / Alternate Contact Email Address

optional

Next of Kin / Alternate Contact Phone Number *

Do you wish to provide your Next of Kin / Alternate Contact with an Authority to Speak on your behalf ? *

Authority to Speak allows the person nominated above to have contact with Guardian Interlock and discuss any aspect of your interlock program record and account information, ie. payments, outstanding fees, program violations etc) including the ability to obtain an unlock code. If you wish to remove this person’s Authority to Speak or change to a different Authority to Speak you can do this at any time by contacting Guardian Interlock Systems on 1300 881 005. Please note this information is for Guardian Interlock Systems use only and will not be shared with government authorities. It will only be used in cases where a participant is uncontactable after multiple attempts.

INSTALLATION AND PRICING AGREEMENT

DOCUMENTATION

Please find links below for the Guardian Interlock 2030 User Manual, Guardian Compliance Guide and Information brochures. The Terms and Conditions of this agreement are contained in the User Manual and the Fee Schedule is contained in the Compliance Guide. These links will open on a new tab – when completed navigate back to this to form to complete the below acknowledgements.

Documents *

I acknowledge that I have read the 2030 User Manual, Compliance Guide and Information brochure in full

Please acknowledge that you understand the below essential items contained in the Guardian Interlock 2030 User Manual and Guardian Compliance Guide.

Consequences of illegal starts and tampering (including jump starting, hot wiring, circumvention, etc) *

I acknowledge that I have read the Guardian Compliance Guide and understand consequences of illegal starts and tampering (including jump starting, hot wiring, circumvention, etc)

Violation and Service Recalls *

I acknowledge that I have read the Guardian Compliance Guide and understand Violation and Service Recalls

Lockout arrangements extra expense to program *

I acknowledge that I have read the Guardian Compliance Guide and understand lockout arrangements can cause extra expense to program

Power disconnections and consequences (Vehicle battery) *

I acknowledge that I have read the Guardian Compliance Guide and understand power disconnections and consequences (Vehicle battery)

End of Program arrangement *

I acknowledge that I have read the Guardian Compliance Guide and understand End of Program arrangements

Afterhours emergency service support (technical assistance only) *

I acknowledge that I have read the Guardian Compliance Guide and understand that an afterhours emergency service support line is available (for technical assistance only)

Complaints and disputes procedure *

I acknowledge that I have read the Guardian Interlock 2030 User Manual and understand the complaints and disputes procedure

Disclosure of Information to authorities and nominated recipients *

I acknowledge that I have read the Guardian Interlock 2030 User Manual and understand disclosure of information to authorities and nominated recipients is required.

VEHICLE INFORMATION

Do you have the vehicle registration certificate ? *

Select Yes if you have this document and upload a copy below to provide the required vehicle information. Select No If you don’t have a copy available so you can complete the details manually below.

Vehicle Colour *

REGISTERED OWNER DETAILS

Are you the registered owner of the Vehicle ? *

SERVICE AGREEMENT – Please tick the following paragraphs to acknowledge that you have read and understand the service agreement

Service Agreement Introduction

This Service Agreement including the Terms and Conditions and Fees Schedule (provided separately), forms the Interlock Driver Contract (IDC) between the client named above and Guardian Interlock Systems Australasia Pty Limited (Guardian) for the provision of services during the client’s participation in the interlock program.

Fees and Charges *

FEES AND CHARGES: The client agrees to pay all fees and charges arising under this Contract in accordance with the Terms and Conditions. Client acknowledges receipt of Guardian’s current Fee Schedule and understands that they may be eligible to concession subject to the rules of the Program. If eligible, a discount will be provided on production of a valid concession card at each service and a signed Centrelink eServices Confirmation form or Centrelink Income Statement.

LOSS PROTECTION PLAN (RECOMMENDED) *

ACCEPT
DECLINE

The client acknowledges and accepts financial responsibility for any damage to, or loss of, the System, however caused, provided that upon payment of the Loss Protection Plan (LPP) fee, the Client’s financial responsibility loss of the System shall be limited to the Loss Protection liability limit amount of $250.00 as shown in the Terms and Conditions & Fee Schedule. Notwithstanding the foregoing, purchase of the LPP shall not limit the Client’s financial responsibility for damage to, or loss of, the System caused by a willful act or omission on the part of the Client or other permitted users of the Vehicle. The Client must present a copy of a Police report, along with any other evidence of loss, and pay the Liability Limit within 72 hours of loss. If the Client declines the LPP, the Client is responsible for payment of complete loss or any part of the System, this cost is outlined in the Fee Schedule. The LPP does not cover outstanding lease fees. Please indicate if you wish to accept of decline by selecting above.

TERM *

TERM: The IDC shall remain in effect until above specified end of program date unless terminated earlier as provided herein, or the program is extended, provided in any event that Client’s obligations hereunder shall continue in full force and effect until the Equipment has been returned to Guardian (or its agents) in good condition subject only to reasonable wear and tear, and all fees and charges paid in full.

AUTHORISATION *

AUTHORISATION: Client authorises and directs Guardian, its agents, employees and/or contractors, to supply the products and/or services described herein, and it in connection therewith, to carry out any work on the Vehicle that is considered necessary or advisable during their participation in the Program. It is expressly acknowledged and agreed that all such work shall be deemed to be in pursuance of, and shall be subject to the IDC. Client also agrees to return the Vehicle for scheduled servicing on the dates advised. Client further authorises Guardian or its agents to recover Interlock equipment from my vehicle if my payments become in arrears or if the vehicle has been impounded.

ACKNOWLEDGEMENT *

ACKNOWLEDGMENT: Client hereby authorises Guardian to provide to the relevant Road Traffic Authority (RTA) your personal information and information on any other user of this device. This information may be disclosed to driver licensing and vehicle registration authorities, law enforcement agencies or other Government agencies that may require it by law. You have a right to access or correct your personal information in accordance with the provisions of the relevant privacy legislation. The Client agrees that Guardian may use and transfer personal information to an overseas database for the purpose of administration of the Program. I, the Client, hereby acknowledge that prior to submitting this form I have read and accept the Contract, including the Terms and Conditions found in the User Instructions. I acknowledge that I may be contacted via Telephone, SMS, Email or other electronic methods in regard to elements of the Alcohol Interlock Program/Scheme.

Declaration *

I, the abovementioned participant, confirm that by submitting this form I have accepted the above service agreement terms and confirm I have provided the correct details above.

TRAINING VIDEO CHECKLIST DECLARATION

Select the below link to watch the training video. This video along with the User Manual and Compliance Guide covers all of the below listed information which you have previously acknowledged. This video forms part of your training and the below declaration acknowledges that you have watched and understood the below topics.

2030 Training Video

Interlock Program knowledge *

I acknowledge that I have watched the training video and understand how the program works

Instructions on use of the interlock system *

I acknowledge that I have watched the training video and understand how to use the interlock system

Delivery of proper breath samples, troubleshooting techniques and Head Unit messages for aborted breath samples *

I acknowledge that I have watched the training video and understand the delivery of proper breath samples, troubleshooting techniques and Head Unit messages for aborted breath samples

Random retesting and consequences – Pull Over to complete retest – Missed Retests and recalls – Flashing lights and siren *

I acknowledge that I have watched the training video and understand random retesting and their consequences

Consequences of failed tests and retests, especially inability to start car. *

I acknowledge that I have watched the training video and understand consequences of failed tests and retests, especially inability to start car.

BAC fail results – 5 min & 30 min Lockout periods *

I acknowledge that I have watched the training video and understand BAC fail results result in 5 min & 30 min lockout periods

Service Arrangements – responsibility to comply with service date set. *

I acknowledge that I have watched the training video and understand service arrangements and my responsibility to comply with service date set.

Food and alcohol consumption before testing *

I acknowledge that I have watched the training video and understand the affects of food and alcohol consumption before testing

How to get assistance *

I acknowledge that I have watched the training video and understand how to get assistance

Declaration *

I, the abovementioned participant, confirm that by submitting this form I acknowledge that I have watched the Training Video with training and information about each of the above subjects, and I have read the User Manual and Compliance Guide.

Please note if you have any queries regarding any of these items please contact Guardian on 1300 881 005 to discuss or speak to a Guardian Service Centre.