MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Ignition Interlock Participation Agreement
Minnesota Ignition Interlock Device 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. Please retain a copy for your own records. Your application will not be complete until all enrollment documents have been received by DVS. For questions, contact DVS at (651) 296-2948 or visit http://dvs.dps.mn.gov.
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Driver Information
Driver’s License Number |
State of Issue |
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First NameMiddle NameLast Name
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AddressCity/State/Zip
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Home Telephone Number/Cell Phone |
Date of Birth |
Certification
I understand that I must have an ignition interlock device in each vehicle that I operate during the entire time that I am subject to an ignition interlock restriction and that the device must be calibrated and maintained in accordance with Minnesota law. The only exception to this is an approved employment variance granted by Driver and Vehicle Services.
I acknowledge that I have received, reviewed and agreed to abide by the Minnesota Ignition Interlock Device Program Guidelines.
I understand that any violation of the conditions outlined in the Program Guidelines may result in sanctions being imposed. These sanctions may include an extension of my time on the program and/or non-credit for the revocation time period spent using the ignition interlock device. Violations include:
∙Tampering, circumventing or bypassing the device
∙Operating a vehicle without the ignition interlock device
∙Violation of the ignition interlock limited license
∙Failure to provide at least 30 initial breath tests each month – a month is considered a 30-day period (verification of abstinence – applies to cancelled-IPS drivers only)
∙Three (3) skipped rolling retests within a six (6) month period
∙An initial start alcohol reading at or greater than .02 with no retest or a retest at or greater than .02 within 15 minutes
∙A rolling retest alcohol reading at or greater than .02 with no passing retest within 10 minutes
I agree that the State of Minnesota, its representatives and employees are not liable for any result of property damage and/or injury or death to persons which may arise, directly or indirectly, during the use of an ignition interlock device. I verify the information on this document is truthful and accurate. I understand that any false information provided may result in termination of my participation in the Minnesota Ignition Interlock Device Program.
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