Fillable Form F4862 CFD Queensland Alcohol Ignition Interlock Exemption Application

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Form F4862 CFD Queensland Alcohol Ignition Interlock Exemption Application

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The Form F4862 CFD Queensland Alcohol Ignition Interlock Exemption Application form is 3 pages long and contains:

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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*.
continued page 2...
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)
/ /
Print Form
Reset Form
Alcohol Ignition Interlock Program - Interlock Exemption Application ... continued page 2 of 3
Yes
No
Go to 6
Go to 7
Do you live on an island where there is no interlock installer,
the island is not connected by a bridge to the mainland or to
another island that is connected to the mainland by a bridge,
and the island is not an excluded island (as outlined on page
1).
Yes
No
If you also answered no to parts 3, 4 and 5 you do
not meet the criteria for an interlock exemption.
Select the category that applies to your
circumstance.
3. Medical condition details
4. Remote location details
5. Island details
Yes
Yes
No
No
You will need to provide an Alcohol Ignition Interlock
Program - Medical Certifi cate for Interlock Exemption
Application (form F4864) completed by your doctor.
Go to 4
Go to 7
Go to 5
Go to 7
Address of the nearest interlock installer or central
post offi ce if the area is serviced by a mobile installer
Do you have a medical condition that prevents you from
providing a suffi cient breath sample to operate an approved
interlock?
Do you live outside a radius of 150km from the nearest
interlock installer and, if the interlock provider offers a mobile
service, outside a 150km radius from the central post offi ce of
the township that the mobile service operates from?
Postcode
2. Driver licence details
Yes
Yes
No
No
Driver licence number (if known)
Driver licence number (if known)
Expiry date
Expiry date
State/Territory/Country of issue
/ /
/ /
(a) Do you hold or have you ever held a Queensland driver
licence?
(b) Do you hold a driver licence issued to you by another
Australian state, territory or country?
If you answered Yes, you must provide evidence of
residency. See Evidence of Residency below.
A
B
C
D
Outline your circumstances over the page (attach a
separate sheet if required).
To support your application you must satisfy all of
the following requirements:
• provide verifi cation from an approved interlock
provider that it is not physically possible to fi t an
approved interlock to your vehicle
• demonstrate that this is the only vehicle
reasonably available to you
• provide evidence that refusal to grant an
exemption would cause you or a member of your
family severe hardship
• demonstrate that no other transport is reasonably
available to you or your family member.
Outline your circumstances over the page (attach a
separate sheet if required).
To support your application you must satisfy all of
the following requirements:
• provide an Alcohol Ignition Interlock Program
- Medical Certifi cate for Interlock Exemption
Application (form F4864) completed by your
family member’s doctor
• demonstrate that only one vehicle is reasonably
available to you or your family member
• provide evidence that refusal to grant the
exemption would cause you severe hardship
• demonstrate that no other transport is reasonably
available to you or your family member.
Outline your circumstances over the page (attach a
separate sheet if required).
To support your application you must satisfy all of
the following requirements:
• provide evidence that refusal to grant an
exemption would cause you severe hardship in
a way other than because you will be prevented
from driving for employment or educational
reasons
• demonstrate that no other transport is reasonably
available to you.
Outline your circumstances over the page (attach a
separate sheet if required).
To support your application you must satisfy all of
the following requirements:
• provide evidence that refusal to grant an
exemption would cause a family member severe
hardship in a way other than because you will be
prevented from driving them to or from their place
of employment or education
• demonstrate that no other transport is reasonably
available to your family member.
continued page 3...
Page 2 of 3 TRB Forms Area Form F4862 CFD V01 Jan 2014
6. Severe hardship details
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.
Will you or your family experience severe hardship (under
category A, B, C or D as outlined on page 1) if you are
required to only drive a nominated vehicle that has been fi tted
with an approved interlock?
If you answered Yes, you must provide evidence of
residency. See Evidence of Residency below.
You must provide an accepted evidence of residency document
for the residential address you provided for Question 1.
For example, contract of property purchase, lease/rental
document, mortgage/land owner certifi cate, electricity/phone/gas
account, rates notice, land tax valuation notice, bank statement
or Australian Tax Offi ce assessment/tax fi le number confi rmation
notice.
Evidence of Residency
Page 3 of 3 TRB Forms Area Form F4862 CFD V01 Jan 2014
Alcohol Ignition Interlock Program - Interlock Exemption Application ... continued page 3 of 3
Provide details (attach a separate sheet if required)
Offi ce Use Only
Offi ce stamp/application received:
Receipt number
Do you approve this application?
Document/File ID
Yes
No
Decision
It is an offence under the Transport Operations (Road Use
Management) Act to state anything or provide a document to a
departmental offi cer if you know it contains false or misleading
information. The maximum penalty may exceed $6000.
Privacy Statement: The Department of Transport and Main Roads provides
this form under the Transport Operations (Road Use Management) Act so that
you may apply for an exemption from the Alcohol Ignition Interlock Program
requirement that only allows you to drive a nominated vehicle that has been fi tted
with an approved interlock. The information collected on this form is accessible by
authorised departmental persons and some of this information may be disclosed
to the Queensland Police Service and interstate driver licensing authorities. The
Department of Transport and Main Roads will not disclose your personal details
to any other third parties without your consent unless authorised or required by
law.
I declare that the information I have provided in this application
is complete, true and correct in every detail. I understand
that failure to provide complete, true and correct information
may result in my application being refused, or if an interlock
exemption is granted on the basis of this information, the
exemption will be absolutely void and have no legal effect
whatsoever.
I understand that I may be prosecuted for giving or stating any
false or misleading information in relation to this application.
I authorise a departmental offi cer to make any enquiries
considered necessary for the purpose of this application.
7. Declaration
Applicant’s signature
Date
/ /
Reasons for the decision
Delegated person’s name
Signature
Date
/ /
Position/title
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Form F4862 CFD Queensland Alcohol Ignition Interlock Exemption Application

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Completed 26 January 2020

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