New Client Intake | Speedy Interlock

New Client Intake Form

First Name

Middle Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Driver's License Number

DL State

Address on DL (if other than current address above)

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Date of Birth

Phone

Opt-in to receive appointment reminders

Emergency Contact #1 Name

Emergency Contact #1 Phone Number

Emergency Contact #2 Name

Emergency Contact #2 Phone Number

Vehicle Information

Make

Mileage

Model

License Plate Number

Vehicle Identification Number (VIN

Year

Color

License Plate State

Vehicle Owner Name (if other than yourself)

Phone Numer

The EEP will cover the replacement cost of the $1,000 handset and $1,400 blocker if stolen or damaged with a $500 deductible

How Did Your Hear About Us/Referral?

Client Signature (Printed)

Owner Signature (Printed)

Today's Date

Electronic Signature Agreement: By electronically printing your name, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. You consent to be legally bound by this documents term's and conditions. Your further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Speedy Ignition Interlock or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by your in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between your and Speedy Ignition Interlock.

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