Dvs Form Ps31208 02 PDF Details

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QuestionAnswer
Form NameDvs Form Ps31208 02
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesIgnition Interlock VoluntaryWithdrawalForm withdrawal from interlock mn form

Form Preview Example

Voluntary Withdrawal from the Ignition

Interlock Device Program

Instructions: If you are voluntarily withdrawing from the Ignition Interlock Device Program, you must use this form to notify Driver and Vehicle Services (DVS). Credit will be given for time spent on the program.

This form can be faxed to (651) 797-1299. You may also bring this form to any Driver Exam Station (Visit the DVS Website for all Office Locations) or mail this form to Driver and Vehicle Services, Ignition Interlock Unit, 445 Minnesota Street, Suite 177, St. Paul, Minnesota 55101. For questions, contact DVS at (651) 296-2948 or visit dvs.dps.mn.gov.

I, ________________________________________________, am voluntarily withdrawing from the

(First Name)

(Middle Name)

(Last Name)

Minnesota Ignition Interlock Device Program. I understand that my driving privilege will no longer be valid

and/or limited.

Driver’s License Number

____________________________________________________________________________________

First NameMiddle NameLast Name

____________________________________________________________________________________

AddressCity/State/Zip

____________________________

________________________

Home Telephone Number/Cell Phone

Date of Birth

____________________________________________________________________________________

Signature

Date

PS31208-02

REV.8/11

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