Vehicle Installation Authority Form – Guardian Interlock

Vehicle Installation Authority Form

Authorisation *

I authorise Guardian to install an interlock device into the vehicle stated below for use of the person stated below during his/her interlock period as the owner of the vehicle. I further authorise Guardian or its agents to recover the Interlock equipment from my vehicle should the participants payments become in arrears or the vehicle be impounded. I acknowledge that Removal charges may be incurred.

Interlock Participants Information

Interlock Participants Name *

First

Last

Interlock Participants Address *

Address Line 1

City

State / Province / Region

Postal Code

Interlock Participants Phone Number *

Interlock Participants Email *

Registered Owner of the Vehicle

Is this vehicle owned by a company or Individual *

Company
Individual

Registered Owner's Address *

Address Line 1

City

State / Province / Region

Postal Code

Registered Owner's Phone Number *

Registered Owner's Email *

Relationship to the Interlock Participant *

Date *

Nominated Vehicle

Vehicle Type (eg. Hyundai, Toyota, etc) *

Vehicle Year *

Vehicle Colour *

Vehicle Registration Plate *