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Alcohol Ignition Interlock Program -
Interlock Exemption Application
Transport Operations (Road Use Management) Act 1995
This form is to be used if you are applying for an exemption
from the requirement to only drive a nominated vehicle that
has been fi tted with an approved interlock.
You may be eligible for an interlock exemption if you meet one of
the following criteria:
1. Medical condition
You are able to prove that you have a medical condition that
prevents you from providing a suffi cient breath sample to
operate an approved interlock.
2. Reside in a remote location
You are able to prove that your principal place of residence
is outside a 150km radius from the nearest interlock installer’s
place of business and, if the interlock provider offers a mobile
service, your principal place of residence is also outside a
150km radius from the central post offi ce of the township that
the mobile service operates from.
3. Reside on an island
You are able to prove that your principal place of residence is
on a Queensland island where there is no interlock installer,
and the island is not connected by a bridge to the mainland or
to another island that is connected to the mainland by a
bridge. However, if you reside on one of the below islands this
criteria will not apply.
- Coochiemudlo Island - Magnetic Island
- Fraser Island - North Stradbroke Island
- Karragarra Island - Orpheus Island
- Lamb Island - Russell Island
- Macleay Island
4. Severe hardship
Please note that an interlock exemption will not be granted
solely on the ground that you cannot afford the cost of an
approved interlock or that you are unable to fi t an approved
interlock for employment reasons.
You are able to prove that one of the following circumstances
applies:
A. It is not physically possible to fi t an interlock to the only
vehicle reasonably available to you to drive and refusal
to grant the exemption would cause you or a member of
your family severe hardship. You must also demonstrate
that no other transport is reasonably available to you or
your family member.
B. A member of your family has a medical condition that
prevents them from providing a suffi cient breath sample
to operate an interlock, only one vehicle is reasonably
available for you or your family member to drive and
refusal to grant the exemption would cause you severe
hardship. You must also demonstrate that no other
transport is reasonably available to you or that family
member.
C. Refusal to grant an exemption would cause you severe
hardship in a way other than by preventing you from
driving in the course of your employment, or to or from
you place of employment; or to or from an educational
institution that you attend. You must also demonstrate
that no other transport is reasonably available to you.
D. Refusal to grant an exemption would cause a member
of your family severe hardship in a way other than by
preventing you from driving them to or from their place of
employment or, to or from an educational institution that
they attend. You must also demonstrate that no other
transport is reasonably available to your family member.
*Higher rates apply from mobile phones or pay phones.
Supporting documents
You will need to provide documents to support your application:
• For an exemption on the basis of a medical condition you will
need to provide an Alcohol Ignition Interlock Program - Medical
Certifi cate for Interlock Exemption Application (form F4864)
completed by your doctor.
•
For an exemption on the basis of residing in a remote location
or on an island you will need to provide evidence of your
residential address. Please refer to the Alcohol Ignition
Interlock Program - Interlock Exemption Information Sheet
(form S4863) for a full list of accepted evidence of residency
documents.
• For an exemption on the basis of severe hardship you will
need to provide evidence to satisfy the department that your
situation meets the relevant severe hardship criteria, including
if applicable an Alcohol Ignition Interlock Program - Medical
Certifi cate for Interlock Exemption Application (form F4864)
completed by your family member’s doctor.
Additional information
The lodgement of this application does not guarantee it will be
approved. Your application cannot be considered at the time of
lodgement. It must be forwarded for consideration. You will be
advised of the outcome.
You may lodge the application and pay the application fee
(cash, cheque, EFTPOS and major credit cards - a credit card
surcharge will apply. For further information please go to
www.tmr.qld.gov.au/creditcard) at your nearest departmental
customer service centre.
The application may also be lodged together with the application
fee (cheque or money order) by mail to:
Department of Transport and Main Roads
Interlock Processing Unit
GPO Box 2451
Brisbane Qld 4001
The application fee is non-refundable except under special
circumstances.
For information about the application fee, or to obtain a copy
of the Alcohol Ignition Interlock Program - Interlock Exemption
Information Sheet (S4863), or the Alcohol Ignition Interlock
Program - Medical Certifi cate for Interlock Exemption Application
(form F4864) visit www.tmr.qld.gov.au or call 13 23 80*.
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Page 1 of 3 TRB Forms Area Form F4862 CFD V01 Jan 2014
1. Applicant’s details
Family name (please PRINT)
Given name/s (please PRINT)
Residential address
Postal address (if same as residential, write ‘AS ABOVE’)
Postcode
Postcode
Daytime contact phone number Mobile phone number (optional)
Date of birth Email address (optional)
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