Fillable Printable Employer Declaration for Ignition Interlock Exemption - Washington
Fillable Printable Employer Declaration for Ignition Interlock Exemption - Washington
Employer Declaration for Ignition Interlock Exemption - Washington
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, your employer
requires you to drive a vehicle without an IID, AND you meet eligibility requirements.
Eligibility and wait period
To be eligible for an employer exemption, you must have an IID installed in your personal vehicle. In addition, there is a wait
period during which time you may not drive an employer owned vehicle without an IID. This wait period is a specific number
of days (below) from the date your suspension / revocation began as a result of the conviction, or date the IID was installed,
whichever is later:
• First alcohol/drug conviction – 30 days
• Second or subsequent alcohol/drug conviction – 365 days
Exemption
If you meet eligibility 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
• Email, fax, or mail this completed form to:
Restricted License
Department of Licensing
PO Box 9030
Olympia, WA 98507
Email: [email protected]a.gov
Fax: 360-570-7824
Employee
PRINT OR TYPE Name of applicant (Last, First, Middle initial)
Washington driver license number Date of birth (Area code) Daytime telephone number
Employer
Name of employer or representative name Company (Area code) 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 declare 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
We are committed to providing equal access to our services.
DR-500-025 (R/12/13)WA If you need accommodation, please call (360) 902-3900 or TTY (360) 664-0116.
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