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Get and Sign Dc Interlock Form
Number
Date Issued State
License Number
Have you ever been convicted for causing injury or death while operating a motor vehicle? Yes No
Have you participated in an IID program within the last five (5) years? Yes No If yes, where? __________
VIOLATION HISTORY* (Begin with the most recent drug/alcohol related traffic offense)
Date
State
Violation
Convicted
Date
State
Violation
Yes No
Yes No
Convicted
Yes
No
Yes
No
VEHICLE INFORMATION* (List all vehicles operated by applicant. Only DC...
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