Ignition Interlock Device Agreement

PERSONAL INFORMATION

Last Name*

First Name*

Middle Name

Suffix

Date of Birth*

Social Security #

Mailing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Employer

Email Address

Driver's License #

State of Issue*

Expiration Date*

Relative/Friend*

ReIative/Friend Phone Number*

Relative/Friend*

ReIative/Friend Phone Number*

Status (choose one)*

Other

LEGAL INFORMATION/WHO NEEEDS REPORTS

Case Number

Judge's Name

Judge's Number

Probation Officer

Probation Officer's Phone Number

Parish*

Attorney Name

Attorney Phone Number

VEHICLE INFORMATION

Year*

Make*

Model*

Color*

Vin #*

License Plate #*

Odometer Mileage

Client Signature*

I hereby certify that the above statements are true and correct to the best of my knowledge.

Date*

Westco Breathalyzers, LLC RENTAL AGREEMENT

I understand that Westco Breathalyzers, LLC, located at 810 N. Columbia Street in Covington, Louisiana, is the company I rent the ignition interlock device from and performs all services on said device.

I agree to pay rent in the amount of $85.00 per month each month that the ignition interlock device is in my vehicle. I understand that this amount includes my calibrations and monitoring of my unit. I further agree to pay said rental each month by the day of each month that corresponds with my install date. If rent is not paid on or before this date each month, I will not be serviced by Westco Breathalyzers, LLC.

I understand that once rent is past due, I will be charged $15 per week as a late fee.

I understand that all service fees (this includes ALL removal and travel fees if vehicle is wrecked, inoperable, or being repossessed) are to be paid to Westco Breathalyzers, LLC on the date of service.

Once I have received my paperwork from Westco Breathalyzers, LLC, I will go to OMV to get my hardship license, and/or tum my paperwork in to my probation officer.

I understand that if the ignition interlock device that is installed in my vehicle is damaged in any way, then I must pay Westco Breathalyzers, LLC $1,600.00 to replace said device.

I understand it is my responsibility to find out my eligibility for removal of my ignition interlock device.

Client Signature*

I HAVE READ AND UNDERSTAND THIS AGREEMENT, AND I ACCEPT AND AGREE TO ALL OF ITS TERMS AND CONDITIONS. I ENTER INTO THIS AGREEMENT VOLUNTARILY, WITH FULL KNOWLEDGE OF ITS EFFECT.

Date*

NOTE: If you have a medical condition, please let the installer know before installation. Also, it is against Louisiana law to tamper with the ignition interlock device. Any damages done to the ignition interlock device will be payable by the customer.

CREDIT CARD AUTHORIZATION

Name on the Card*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card Type*

Credit Card Number*

Expiration Date*

Card Identification Number*

I AUTHORIZE WESTCO BREATHALYZERS, LLC TO CHARGE THIS CREDIT CARD FOR ALL FEES.

CARDHOLDER-PLEASE SIGN AND DATE

Client Signature*

Date*

IMPORTANT INFORMATION – PLEASE READ

No mouthwash, coffee or toothpaste at least 15 minutes.
Do not blow into machine while eating, smoking or drinking any beverage (especially drinks containing alcohol or drinks containing high amounts of sugar) or chewing gum.
High sugar foods/drinks can affect alcohol BAC.
You must take all retests, otherwise you will get a violation.
An error on Non-Human breath can result in a violation unless you put your fingers over the lights next to the mouth piece.
If you become locked out due to not being calibrated on time you will be charged a fee of $25.00 for a code.
I understand that if l have a violation I will be charged $65.00 for a reset, whether it is related to any of the above.

ALL SERVICE/MAINTENANCE CALLS-COST $65.00 PLUS ADDITIONAL COST FOR TRAVEL TIME

***DO NOT JUMP START CAR WITHOUT REMOVING HANDSET***
IF YOU DO SO, A MINIMUM FEE OF $150 WILL BE CHARGED TO YOU, AS WELL AS, ANY ADDITIONAL COST OF NEW EQUlPMENT.

*** ANY ATTEMPT TO DISCONNECT HEAD FROM COILED CORD WITHOUT VERBAL CONSENT FROM WESTCO COULD COST YOU A FINE OF $250.00***

***ATTEMPTING TO DISCONNECT HEAD FROM COILED CORD CAN CAUSE DAMAGE TO HEAD CONNECTION AND LOGGER. THEREFORE, COSTOMER WILL BE RESPONSIBLE FOR ANY COST FOR DAMAGES***

Client Signature*

I HAVE READ AND UNDERSTAND THIS AGREEMENT, AND I ACCEPT AND AGREE TO ALL OF ITS TERMS AND CONDITIONS. I ENTER INTO THIS AGREEMENT VOLUNTARILY, WITH FULL KNOWLEDGE OF ITS EFFECT.

Date*

Comments

This field is for validation purposes and should be left unchanged.

Ignition Interlock Device Agreement

West Breathalyzers

PERSONAL INFORMATION

LEGAL INFORMATION/WHO NEEEDS REPORTS

VEHICLE INFORMATION

Westco Breathalyzers, LLC RENTAL AGREEMENT

CREDIT CARD AUTHORIZATION

IMPORTANT INFORMATION – PLEASE READ

Contact Us

985-626-0545

Westco Breathalyzer Locations