- NOTICE APPLICATION FEES ARE NON-REFUNDABLE.
Applicants should contact the DMV
DUI-INTERLOCK Section at 1-800-642-9066 or
304-926-2507 for a review of their driving
record before submitting application.

DMV-21-DU

DMV FILE NO:Rev. 05/2021

WV ALCOHOL AND DRUG TEST AND LOCK (INTERLOCK) PROGRAM APPLICATION
PLEASE CALL TOLL-FREE 1-800-642-9066 OR (304) 926-2507 FOR ASSISTANCE

YOU MUST COMPLETE THIS ENTIRE APPLICATION, INITIAL AND SIGN IT WHERE REQUIRED, OR IT WILL NOT BE PROCESSED.

The State of West Virginia may issue restricted driving privileges to a driver who has been revoked due to a DUI offense. The driver
must apply for, and be accepted into, the Alcohol and Drug Test and Lock Program (INTERLOCK). Once accepted into the program,the driver must have an approved ignition INTERLOCK device installed in their vehicle. Individuals interested in the INTERLOCK
program should carefully read and complete this application. Applicants should contact the WV DMV INTERLOCK Section toll-free
at 1-800-642-9066 or (304) 926-2507 with any questions.

APPLICANT INFORMATION
Full Name

Date of Birth

Spouse’s Name

Physical Address (Must present proof for the restricted driver’s license issuance)

CityStateZip

Mailing Address (If different)

CityState

Zip

Social Security Number

Driver’s License NumberHome Phone

Cell Phone

Email

VEHICLE INFORMATION (Class “A” Passenger Type Vehicles With a GVW of 10,000 lbs, or Less, Only)
Name of Registered Owner(s) or Lessee(s) - If other than Applicant, the Owner’s Consent to Installation of the INTERLOCK Device form on page 4 of this application must be completed.
If more than one vehicle is owned and/or operated, please list on a separate sheet.
NOTE: If vehicle is leased, you must complete page 4.
YearMakeModel

VIN

Title Number

License Plate Number

I own more than one vehicle.
Yes

I understand that I can only operate the WV INTERLOCK-equipped vehicle.

No______________ (Initials)

INSURANCE INFORMATION
Insurance Company

Agent Name

Policy Number

NAIC Number"Notice of Confidentiality" The information contained in this document is intended for the use of the individual or entity named above and may contain information thatis privileged, confidential, exempt or protected from disclosure by law. If the reader of this document is not the intended recipient, you are hereby notified that any
disclosure, dissemination, distribution, or copy of this document is strictly prohibited.

Processed By

S&T

Date Enrolled

Revocation Period

Date
Date Completed
Participation Period

Combined Rev. & Part. Periods

WV DMV INTERLOCK Application

PAGE 1 of 5

Fee Balance @ EOP

Date Mailed

Approval Number
Application Fee Processed On:Initials
Date Eligible

ELIGIBILITY REQUIREMENTS
In order to be eligible to participate in the Alcohol Drug Test and Lock Program you must meet the following minimum
requirements, and:1 ) Not have any other revocations, suspensions, or other driving privilege withdrawals in West Virginia or any other state or jurisdiction;2 ) Have an active DUI revocation on your driving record;3 ) Not be appealing the revocation administratively, in Circuit Court, or in Supreme Court;
4 ) Have completed or be enrolled in the Safety and Treatment Program within 60 days after beginning the INTERLOCK Program;5 ) Own the vehicle(s) to be used in the INTERLOCK Program, or have the owner’s written approval, for the installation of the ignition INTERLOCK device;6 ) Be at least 18 years of age. No person under the age of 18 can operate the INTERLOCK-equipped vehicle;
7 ) If you want to avoid your revocation, you must apply and be approved for the INTERLOCK Program before you scheduled revocation date.
Additional requirements may be imposed by the West Virginia Division of Motor Vehicles (DMV).

NON-WV RESIDENT PARTICIPANTS
1 ) If accepted into the Program, the driver bears the burden of communication with all agencies concerned to ensure their participation efforts can be credited.
2 ) In all situations, the INTERLOCK and Positive ID device must be installed by a WV-approved ignition INTERLOCK device service provider.
3 ) Once admitted to the Program, you must participate for the minimum period required by the WV law. The INTERLOCK participation period required by your state ofresidence may be shorter than the participation required by WV. If this should apply, you will be required to participate for the WV required period.
4 ) Once admitted to the Program, you will be required to provide a certified driving record from your licensing state every 6 (six) months.
5 ) Any DUI Safety and Treatment program taken outside of WV must be approved by the WV DMV Safety and Treatment Unit. You can contact them at (304)926-0723
to receive instruction on how to get an out-of-state program approved.

PROGRAM REQUIREMENTS FOR APPROVED PARTICIPANTS

Once you are approved for the Alcohol and Drug Test and Lock Program and ignition INTERLOCK device:1 ) You will receive written notification from DMV with an approval number and a list of authorized ignition INTERLOCK device service providers to choose from. You must
contact the service provider you choose to schedule an installation appointment. You must have the ignition INTERLOCK device/camera installed within 6 (six) monthsof the date of application for the INTERLOCK Program or your application will be deemed expired.
2 ) You must be driven to the appointment for the ignition INTERLOCK device installation and to DMV by a licensed driver.
3 ) Vehicles must be manufactured after 1988 and may require an inspection to verify vehicle is equipped with OBD I (On Board Diagnostics Generation 1) in order for theignition INTERLOCK device/camera installed. Give the ignition INTERLOCK service provider the make/model/year of your vehicle when making the installation appointment.
4 ) You will be required to return to the installation center at least every 30-60 days for vehicle monitoring, so data can be downloaded from the device/camera andreported to DMV.
5 ) You will be considered in violation of the INTERLOCK Program, and subject to removal from the program, for any violations including, but not limited to:• Failure to report for device monitoring every 30 days, or as scheduled;• If DMV receives notice from any law enforcement officer, DMV employee, or INTERLOCK service provider that indicates you operated a vehicle not equipped with anignition INTERLOCK device;• Failure to abide by the service agreement with the INTERLOCK service provider;• If the participant or anyone else, aside from the INTERLOCK service provider, is found tampering with, bypassing, or removing the INTERLOCK device and/or camera;• If the camera is moved or covered (which is considered tampering and is prohibited);• Any obscene gestures and/or display by the INTERLOCK participant or anyone in the vehicle;• Attempting to start, or operate, the vehicle while under the influence of alcohol, intoxicant, drug or any combination of these;• Failure to submit to and pass any retests prompted by the INTERLOCK device after the vehicle has been started;• Failure by the participant to actively use the ignition INTERLOCK-equipped vehicle frequently and regularly will result in extension of participation time ordisqualification from the INTERLOCK Program;• If you fail to enroll in, have no progress in, or withdraw yourself from the DUI Safety and Treatment Program; or• If someone other than the person driving the INTERLOCK-equipped vehicle blows into the INTERLOCK device;• Failure to provide a copy of your resident state's driver's license to WV DMV within 30 days of having the INTERLOCK device installed;• Failure to provide a copy of the required monthly drug test if participating with a controlled substance offense;• If there is a positive result on the required monthly drug test that is not consistent with prescribed medication if participating with a controlled substance offense;

WV DMV INTERLOCK Application

PAGE 2 of 5

APPLICANT CERTIFICATION
I have read the Alcohol and Drug Test and Lock Program Participant Requirements, as specified under WV Code §17C-5A-3a (found atlegis.state.wv.us) and WV Administrative Regulation 91CSR5 (found at sos.wv.gov), and agree to those requirements. I understand that myparticipation in the program is restrictive, and I am subject to removal from the program for violating any of the terms and conditions imposed
upon me. Furthermore, I understand:1 ) I must have successfully completed an approved DUI Safety and Treatment Program; or be actively enrolled in a DUI Safety and Treatment Program, within 60 days ofhaving the ignition INTERLOCK device installed on the vehicle. Completion of the Safety and Treatment Program must be received prior to my scheduled removal date. I
understand that the INTERLOCK device will not be removed after my minimum participation time has been served if the completion of the Safety and Treatment
program has not been received by the DMV. Failure to comply with these terms may result in removal from the INTERLOCK Program.
2 ) I must abide by the terms of the service agreement with the ignition INTERLOCK device Service Provider, and will contact the DMV 30 days prior to my scheduled
removal date to ensure all program paperwork is present all reinstatement fees are paid in full, and understand that failure to comply with this requirement may
extend my program participation period.
3 ) That, as this is a participation-based program, it is essential that I operate the INTERLOCK-equipped vehicle frequently and regularly. Lack of use, or non-usage, of
the ignition INTERLOCK-equipped vehicle is considered a violation of the program. Failure to provide adequate written explanation for such instances will result inprogram disqualification. Removal from the INTERLOCK Program due to non-compliance of the rules governing the program including, but not limited to, theconditions listed in this section, shall result in the immediate loss of any restricted driving privileges provided by participation in this program.
4 ) That, if participating in the INTERLOCK Program with a controlled substance offense, I must provide the DMV with a list of all prescribed medications. Any time there
is a change in my prescribed medication, I will provide an updated list to the DMV. The drug testing facility must provide the results of a random drug test directly tothe DMV every month during my participation. Any inconsistent results on any drug test will result in my disqualification and immediate removal from the INTERLOCK
Program. Failure to comply with these terms will result in my immediate removal from the INTERLOCK Program.
5 ) That any pending DUI or Driving While Suspended or Revoked charges, not yet received by the DMV, may change my INTERLOCK Program participation and eligibility status.

I hereby declare under the penalties of perjury that all the information contained herein is true and accurate to the best of my knowledge,
information, and belief.
Applicant’s Signature

Date of Application(X)

WV Licensed Applicants• If approved for the INTERLOCK Program, you will receive written notification by mail. Should your application for the program be declined, the DMV will send you
written notification with an explanation as to why your application was rejected.
• Upon installing an INTERLOCK device in your vehicle, the DMV will fax an authorization letter to your chosen provider so you may obtain your restricted driver’s license.
• You cannot operate your INTERLOCK-equipped vehicle until you have received your restricted driver’s license, which can only be used to operate a vehicle inwhich an approved functioning ignition INTERLOCK device has been installed, and then only under the conditions set forth in this application.

Non-WV Resident Applicants• If approved for the INTERLOCK Program, you will receive written notification by mail. Should your application for the program be declined, the WV DMV will send youwritten notification with an explanation as to why your application was rejected.
• You will be required to submit the installation documentation to the WV DMV once you have the INTERLOCK device installed. You can fax this to (304) 957-0414 or
mail to the WV DMV P.O. Box 17060 Charleston, WV 25317. Upon receipt of this documentation, the WV DMV will "clear the hold" on the National Drivers' Registry.
You should be able to obtain your license within one to three business days.
• You cannot operate your INTERLOCK-equipped vehicle until you have received your driver's license. You can only operate a vehicle in which an approved
functioning INTERLOCK device has been installed, and then only under the conditions set forth in this application.

WV DMV INTERLOCK Application

PAGE 3 of 5

Rev. 05/2021

VEHICLE OWNER’S CONSENT TO INSTALLATION OF AN IGNITION INTERLOCK DEVICE*IF THE VEHICLE IS LEASED, THE APPLICANT MUST HAVE CONSENT FROM LEASING COMPANY.*THIS PAGE MUST BE COMPLETED IF THE VEHICLE IS NOT REGISTERED IN THE NAME
OF THE ALCOHOL AND DRUG TEST AND LOCK (INTERLOCK) PROGRAM APPLICANT.
REGISTERED VEHICLE OWNER INFORMATION AND CERTIFICATION
I, the undersigned, do hereby swear or affirm that:
1 ) I am the registered owner or lessee of the vehicle(s) described on page 1 (one).
2 ) I agree to the use of the vehicle by the applicant, described on page 1 (one) of this application, for their participation in the INTERLOCK Program.
3 ) I agree to the provisions of the INTERLOCK Program with the Division of Motor Vehicles and it’s authorized service provider.
4 ) In the event that the applicant leaves the INTERLOCK Program, I will bring the vehicle to the service provider for the removal of the INTERLOCK device
within 5 (five) days of their being terminated from the INTERLOCK Program.
Registered Owner’s Printed Name

Registered Owner’s Signature(X)Street Address

CityState

Relationship to Applicant

Contact Phone NumberZip CodeThe above describedvehicle is being used for: ___________________________________ ___________________________ __________________
Applicant’s Printed Name

Driver’s License Number

DMV FILE Number

N OTA R Y S EA L
Subscribed and sworn before me this ______ day of ___________________, 20_____.
______________________________________________________________________NOTARY PUBLIC SIGNATURE//

My commission expires on ______ ____ __________.

DMV REGIONAL OFFICES CANNOT PROCESS THIS APPLICATION OR ANY REINSTATEMENT FEES.
THIS APPLICATION WILL NOT BE PROCESSED WITHOUT COMPLETED VIOLATION POLICY (ENCLOSED).
YOU MUST MAIL THIS APPLICATION WITH AN APPLICATION PROCESSING FEE OF $100.00
PAYABLE BY CHECK OR MONEY ORDER TO “WV DMV” AT THE FOLLOWING ADDRESS:WV Division of Motor Vehicles
PO Box 17060Charleston, WV 25317
The $100.00 INTERLOCK Program application processing fee is NON-REFUNDABLE.

WV DMV INTERLOCK Application

PAGE 4 of 5

Rev. 05/2021

WV ALCOHOL AND DRUG TEST AND LOCK (INTERLOCK) PROGRAM VIOLATION POLICYAll participants of the WV INTERLOCK Program are governed by the following violation policy. This violation policy has been established to formalize theDivision of Motor Vehicles’ procedure regarding events recorded during participation in the INTERLOCK Program. Violations may cause an extension ofthe participation period and/or disqualification from the Program. The service provider may also charge a fee when a violation occurs. The DMV shallreview downloads and other factors for program compliance.

ADDITIONAL PENALTY TIME WILL BE ASSIGNED AS FOLLOWS PER DOWNLOAD:
1 Month Violations2 Month Violations

Warning - BrAC reading of .020 to .024
Fail - BrAC reading of .025 to .049

High Fail - BrAC reading of .050 or higher
Three missed appointment charges
Running retest violations

Breath alcohol content (BrAC) readings may be reported to the Safety and Treatment (S&T) facility where you are
currently enrolled. If you have completed the S&T program but continue to provide BrAC readings, it is possiblethat your completion will be voided. If this occurs, you will be required to go back to your S&T provider forreassessment and completion of further services if deemed clinically necessary.
INTERLOCK is a participation-based program. To actively participate you must operate the INTERLOCK-equipped vehicle frequently and regularly. Simply
having the device in a vehicle or simply starting the vehicle is not enough. You, the program participant, must start and operate the vehicle long enoughfor retests to occur and do so multiple days per week. You cannot be given credit for others driving the vehicle. Failure to operate the INTERLOCK-equippedvehicle frequently enough may result in days of non-operation being added to the participation time. Continued failure to operate the vehicle may resultin disqualification. Additionally, please be aware that no person under the age of 18 is permitted to operate an INTERLOCK-equipped vehicle.

Violations requiring automatic removal:• Tampering with or bypassing the INTERLOCK system and/or camera device, including moving or blocking the camera• Driving an unequipped vehicle• Any arrest for driving while under the influence of any intoxicant, alcohol, drug, or combination of these• Failure to participate in and/or successfully complete the DUI Safety and Treatment Program• Any evidence of intentional circumvention of INTERLOCK system or rules by any individual or party• Allowing another person to provide a breath sample• Any obscene gesture and/or display by the INTERLOCK participant or anyone else in the equipped vehicle• Failure to submit results of the required monthly drug test if participating with a controlled substance offense• Positive results not consistent with prescribed medication on the required monthly drug test if participating with a controlled substance offense

No participation will be deemed completed if any BrAC readings are recorded during the last two regularlyscheduled monitoring downloads.
APPLICANT PROGRAM VIOLATION POLICY CERTIFICATIONI hereby declare that I have read and understand the West Virginia INTERLOCK Violation Policy as outlined in this document. I understand that
additional participation time may be added when the issues listed are present. I understand that if I fail to operate the INTERLOCK-equippedvehicle frequently and regularly, days of non-operation may be added. Additionally, I understand that non-compliance with the issues outlinedin this policy may result in disqualification from this program.
Applicant’s SignatureDate(X)WV DMV INTERLOCK Application

PAGE 5 of 5

Driver’s License Number