ALCOHOL FREE STARTS: 501,947,950
ALCOHOL STARTS PREVENTED: 6,473,440

Save $5 off your installation and speed up your process by completing and submitting the enrollment form below:

Pennsylvania Services

Enrollment Information
Last Name*
First Name*
Middle Initial
Address
Apt #
City
County
State
Zip Code
DOB
Driver License Number
Home Phone
Work or Cell Phone
Email*
Fax
Date of Arrest
County of Arrest
Residing County
Exact date of eligibility for interlock license restoration as found on your Penn DOT letter:
On active probation?: Yes No
If yes, name and address of PO
Number of vehicles titled in your name:
Will more than one vehicle need an interlock? Yes No
Vehicle Info for installation:
Year:
Make:
Model:
State:
Plate:
VIN:
Have you received a Penn DOT form DL 21SC? Yes No
Were you referred by someone? Yes No
If yes, who?


* Required Fields