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Interlock Application Form
First name
*
Last name
*
Phone number
*
Date of birth
*
Scroll & select manually, or enter as YYYY-MM-DD.
Street address
*
Email address
*
Next of Kin first name
*
Next of Kin last name
*
Next of Kin phone number
*
Next of Kin relationship to you
*
Vehicle registration (number plate)
*
Is your vehicle any of the below?
Is your vehicle any of the below?
My vehicle is a standard key start ignition
Push-button ignition
Hybrid
Fully electric
Motorbike
Do you have your alcohol interlock licence yet?
*
Do you have your alcohol interlock licence yet?
A
Yes
B
No
Do you hold a community services card?
*
Do you hold a community services card?
A
Yes
B
No
Almost done! How did you hear about Smart Start?
Almost done! How did you hear about Smart Start?
Google/online web search
Google Maps location
Local service centre told me
Info from the Court
Brochure from AA or VTNZ
A friend recommended it
I've had an interlock before
Other (please specify):
*
Optional: notes/anything extra we should know đ
Submit
