Fillable Printable Employer Declaration For Ignition Interlock Device

Employer Declaration For Ignition Interlock Device

IID ILW

Employer Declaration for

Ignition Interlock Exemption

Use this form if you are required to have an ignition interlock device (IID) installed in all vehicles you drive AND your

employer requires you to drive a vehicle without an IID.

Eligibility

To get an employer exemption, you must have an IID installed in your personal vehicle.

Exemption

If you have an IID installed in your personal vehicle and your employer requires you to drive a vehicle without an IID during

working hours that is owned, leased, rented, or the temporary responsibility of your employer, you must:

• Completetheemployeesectionofthisform

• Haveyouremployercompleteandsigntheemployersection

• Carryacopyofthisformwhendrivingforyouremployer

• Sendthiscompletedformto:

Mail: Restricted Licensing

Department of Licensing

PO Box 9030

Olympia, WA 98507

Fax: 360-570-7824

You may only drive the vehicle(s) during working hours. Employer vehicles assigned exclusively to you that are used

solely for commuting to and from employment are not eligible for an exemption.

Employee

PRINT OR TYPE Name of employee (Last, First, Middle initial)

Washington driver license number Date of birth (Area code) Daytime telephone number

Employer

Nameofemployercontactorrepresentative (Areacode)Companytelephonenumber

Companyname UBInumber

Companystreetaddress

City State ZIPcode

This employee is required to operate a vehicle during working hours that is owned, leased, rented, or in the

temporary care of this company.

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Date and place signed Employer signature

DR-500-025 (R/7/16)WA

Click here to START or CLEAR, then hit the TAB button

Complete Employee section, print out, and have your employer complete and sign.