Draeger, Inc.
3135 Quarry Road
Telford, PA 18969
Phone: (972) 929-1100
Fax: (972) 929-1260
info.usa@draeger.com
USA0208
Owner’s Consent to Installation of Dräger Interlock Device
I, the undersigned, do hereby swear and affirm that I am the registered owner of the below
referenced vehicle and consent to the installation of a Dräger Interlock device in my vehicle:
Year Make Model VIN License Plate Number
I agree to the use of the above vehicle by __________________________________________
in the Dräger Interlock Program. I agree to comply with the Motor Vehicle Administration /
Department of Motor Vehicle’s Authorized Service Provider program requirements. In the event
that the person named above ceases to participate in the program, I agree to bring the vehicle
identified above to a service center for removal of the device within five (5) days of the date that
such person ceased to participate.
Registered Owner Signature
Registered Owner Print Name
Note: If the registered owner above presents proof of identity at the service center, this document may
be witnessed by a representative of Draeger, Inc. instead of a notary public.
Notary: State Of____________________ County of ______________________
On this _______ day of _______________, in the year 20___, Sworn and
Subscribed before me on this date.
___________________________ _______________________________
Notary Public Signature Typewritten or Printed Name
Seal
My Commission Expires _______________________________
Witness:
If the registered owner of the vehicle presents proof of identity at the service center, this
document may be witnessed by a representative of Draeger, Inc. instead of a Notary Public.
_______________________________________________________
. WitnesssignatureforDraeger,Inc.andDate
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