LifeSafer Registration Form

Date of Birth *

Day

Month

Year

Drivers Licence No: *

Phone Number *

Which Service Centre is your preferred choice? *Select from dropdown

Firstname *

Lastname *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Email Address *

Driving Licence Issuing State *

How did you hear about us?

How long will you need a device? *

Preferred contact *

Do you have a concession card? *YesNo

State of Conviction *

County of Conviction *

Program TypeIf you have a provisional licence with an Interlock condition, please select Admin Order.

VEHICLE

Year *0 / 4

Vehicle Manufacturer *

Vehicle Model *

Vehicle registered to you? *YesNo

Name of the person the car is registered to: *

Rego Plate *

VIN number *

Vehicle colour *

Emergency Contact