Fillable SERVICE CENTER CERTIFICATION APPLICATION (Washington)

Fill Online, Printable, Fillable, Blank SERVICE CENTER CERTIFICATION APPLICATION (Washington) Form

Use Fill to complete blank online WASHINGTON pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SERVICE CENTER CERTIFICATION APPLICATION (Washington)

On average this form takes 10 minutes to complete

The SERVICE CENTER CERTIFICATION APPLICATION (Washington) form is 3 pages long and contains:

  • 0 signatures
  • 32 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

BROWSE WASHINGTON FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
IGNITION INTERLOCK PROGRAM
SERVICE CENTER CERTIFICATION APPLICATION
3000-136-021 (R 12/15)
Instructions for completing this application
Before you begin working on this application, please familiarize yourself with Washington
Administrative Code (WAC) 204-50 and chapter 43.43 of the Revised Code of Washington
(RCW) at these web addresses:
http://apps.leg.wa.gov/wac/default.aspx?cite=204-50
http://apps.leg.wa.gov/rcw/default.aspx?cite=43.43.395
If you are not able to obtain a copy of WAC 204-50 or RCW 43.43 from the above web sites,
please contact the Washington State Patrol Ignition Interlock Program (see below) and a copy
will be provided for you.
Washington State Patrol Impaired Driving Section
Ignition Interlock Program
811 E Roanoke St.
Seattle, WA 98102
(206) 720-3018
Please submit the completed application through your respective state director or representative.
They will direct it to the trooper responsible for your geographical area.
If you have not submitted all of the requested items, the Impaired Driving Section (IDS) will
contact your state director or representative regarding the missing items. Incomplete
applications delay processing.
Upon completion of all necessary requirements for certification, the IDS will issue the applicant
an Ignition Interlock Service Center Certification. This certification will be subject to an annual
renewal and to all regulations of WAC 204-50.
A paper certificate with the effective date will be provided by IDS. It will be routed through
your state director or representative to you.
To maintain certification, current proof of insurance and applicable current business
license or licenses must be submitted thirty (30) days prior to annual renewal date.
IGNITION INTERLOCK PROGRAM
SERVICE CENTER CERTIFICATION APPLICATION
3000-136-021 (R 12/15) Page 1 of 2
Draeger Guardian CST-Intoxalock LifeSafer
Smart Start Simple
Business Name
Physical Address
City ZIP Code
( )
County Local Phone Number
Does this physical location comply with all municipal and/or city
zoning regulations for commercial businesses?
Yes No
Does this service center provide a designated waiting area for the
lessee that is separate from the installation area?
Yes No
Are the following items attached?
Copy of Business License
Yes No
Copy of Business Insurance
Yes No
Written statement from Washington State certified
manufacturer authorizing the service of their device
Yes No
Written statement for data download procedures
Yes No On File
List of all fees that may be charged to the lessee
Yes No On File
Will this service center provide mobile service?
Yes No
If YES, please submit a separate Mobile Service Center Certification Application.
Approval of this application does not certify the location to provide mobile service.
Projected opening date:
IGNITION INTERLOCK PROGRAM
SERVICE CENTER CERTIFICATION APPLICATION
3000-136-021 (R 12/15) Page 2 of 2
Service center hours of operation for ignition interlock business:
Day AM PM Closed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I certify, under penalty of perjury under the laws of the state of Washington, that the foregoing
and all included documents are true and correct.
Print Name Title
Signature Date
Do not write below this line.
Approved Denied
Service Center Certification Number
Reviewed By Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

SERVICE CENTER CERTIFICATION APPLICATION (Washington)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document