Alcohol Ignition Interlock Program Apply/Remove a Vehicle Nomination
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Transport Operations (Road Use Management) Act 1995
This form is to be used to apply or remove a vehicle nomination for the Alcohol
Ignition Interlock Program. This form must be lodged with the interlock
provider when you commence or terminate an agreement for an approved
interlock.
While you are subject to the Alcohol Ignition Interlock Program you may only
drive a vehicle that has been fitted with an approved interlock and nominated to
the Department of Transport and Main Roads (the department), via an interlock
provider. You may nominate more than one vehicle; however a separate form
is required for each vehicle. If you no longer wish to drive a nominated vehicle
you may remove the nomination of the vehicle using this form.
The interlock provider will notify the department when you apply or remove
the nomination of a vehicle, and this information will be recorded against your
customer record.
Applying or removing a vehicle nomination will affect the time counted towards
your prescribed period in relation to that vehicle. Your prescribed period will
only commence and accumulate time when you hold a valid Queensland driver
licence and either have a nominated vehicle fitted with an approved interlock or
an interlock exemption.
Multiple interlock drivers may nominate the same vehicle; however additional
requirements may apply in these circumstances (refer to the Alcohol Ignition
Interlock Program - Vehicle Nomination Information Sheet (S4840)). If you are
nominating a vehicle that is already fitted with an approved interlock, you must
lodge this form with the interlock provider that supplied the interlock.
If an approved interlock is removed from a vehicle with multiple nominations,
the nomination of the vehicle will be removed for all interlock drivers who have
nominated the vehicle.
Additional information
The following interlock providers have been approved to supply interlocks for
the Alcohol Ignition Interlock Program.
Guardian Interlock Systems
Telephone: 1300 881 005
Website: www.guardianinterlock.com.au
Draeger Safety Pacific Pty Ltd
Telephone: 1300 780 689
Website: www.draeger.com.au/interlock
For further information regarding vehicle nomination, or to obtain a copy of
the Alcohol Ignition Interlock Program - Vehicle Nomination Information Sheet
(S4840), visit www.tmr.qld.gov.au or call 13 23 80*.
1. Personal details
3. Remove a vehicle nomination
Complete this section to remove the nomination of a vehicle that you no longer
wish to drive.
Vehicle registration number
State of registration
Vehicle identification number (VIN)
The VIN is required for vehicles manufactured after 01/01/1989
Chassis number
The chassis number is required for vehicles manufactured before 01/01/1989
Date of vehicle nomination removal (cannot be backdated)
/
/
4. Registered operator’s authorisation
(If the vehicle is registered in joint names, only one registered operator’s
authorisation is required).
I certify that I am the registered operator of the vehicle identified in part 2 of
this form, and authorise the person named in part 1 to nominate my vehicle for
the Alcohol Ignition Interlock Program.
I understand that an approved interlock will be/has been fitted to the vehicle by
an interlock installer and that the interlock requires regular maintenance.
Registered operator’s name (please PRINT)
Registered operator’s customer reference number
Date
Registered operator’s signature
/
Family name (please PRINT)
/
5. Declaration
Given name/s
Residential address
Postcode
Daytime contact phone number
Date of birth
/
/
Customer reference number (Queensland driver licence number, 18+ card
I declare that the information I have provided in this form is complete, true
and correct in every detail. I understand that I may be prosecuted for giving or
stating any false or misleading information in relation to this form.
I understand that applying and/or removing a vehicle nomination affects the
accumulation of time towards the prescribed period.
I understand that additional requirements apply if multiple persons nominate
this vehicle and that if the approved interlock is removed from this vehicle that
my nomination of the vehicle will be removed.
I authorise a departmental officer to make any enquiries considered necessary
for the purpose of this form.
Driver’s signature
Date
number or adult proof of age card number)
2. Apply a vehicle nomination
Complete this section to nominate a vehicle that you wish to drive while subject
to the Alcohol Ignition Interlock Program.
Vehicle registration number
State of registration
Vehicle identification number (VIN)
The VIN is required for vehicles manufactured after 01/01/1989
Chassis number
The chassis number is required for vehicles manufactured before 01/01/1989
Does the vehicle have an approved interlock already fitted?
No
Name of the interlock provider that supplied the interlock
Yes
Please note: This form must be lodged with the interlock provider that supplied the
interlock.
Are you the registered operator of the vehicle?
The registered operator must complete part 4 of this form.
No
/
/
It is an offence under the Transport Operations (Road Use Management) Act 1995
to state anything or provide a document to an authorised person if you know it
contains false or misleading information. The maximum penalty may exceed $6000.
Privacy Statement: The Department of Transport and Main Roads (the department)
provides this form under the Transport Operations (Road Use Management) Act 1995
so that you may apply or remove the nomination of a vehicle for the Alcohol Ignition
Interlock Program. The information collected on this form is accessible by authorised
departmental persons and some of this information may be disclosed to the Queensland
Police Service and interstate driver licensing authorities. The department will not disclose
your personal details to any other third parties without your consent unless required by
law.
Office Use Only
To be completed by the interlock installer
Date form lodged by customer
/
Time form lodged by customer
/
Interlock installer’s business name
Interlock installer’s location
To be completed by the interlock provider
Date TMR notified via AIPwa
/
/
Interlock provider’s name
Date form sent to TMR
/
/
Processing officer’s name
Yes
*Higher rates apply from mobile phones and pay phones.
SSA Multimedia Services
Form F4841 ES
V01 May 2011