Fill and Sign the Employer Declaration for Ignition Interlock License Form

Employer Declaration for Ignition Interlock License If you are applying for, or have, an Ignition Interlock Driver License, you must:  Carry this completed form when you drive an employer owned vehicle that does not have an ignition interlock device.  Send a copy of this form to: (For example: Driver Records) (For example: Department of Licensing) ____________________________________________ (street address, city, state, zip code) You may only drive this vehicle(s) during working hours. Employee ____________________________________________________________________________________ PRINT OR TYPE — Name of applicant ________________ (Last, First, Middle initial) ____________________ (Name of State) driver license number: _________________ Date of Birth: ________________ Daytime Telephone No.: _________________ Employer Company Name: _______________________________________________________ Telephone No.: ____________________ UBI No.: 1 ______________________ Company street address: ____________________________________ City: ______________________ State: _______________ Zip Code: ____________ This Employee is required to operate a vehicle during working hours that is owned by this Company. I declare under penalty of perjury under the laws of the State of _______________ (name of state) that the foregoing is true and correct. ____________________________ (Printed Name of Employer) ____________________________ (Signature of Employer) 1 Business License Number ______________________________________________________ Date and place of Employer’s signature