Confirmation of Interlock

Department of Finance and Administration
Driver Control

Ragland Building Room 1070

Post Office Box 1272

Little Rock, Arkansas 72203-1272

Phone: (501) 682-1631

Fax: (501) 682-7109

http://www.state.ar.us/dfa
CONFIRMATION OF INTERLOCK REQUIREMENT
Company/Interlock Provider
Customer Name
DL#
DOB

MonthDayYear
This letter is to confirm that the above named client has had a functioning interlock device installed for a period equal to:
Years
Months
Days
Date Installed

MonthDayYear
Date Removed

MonthDayYear
Signature of designated agent

Clear
Should be Empty:

Department of Finance and Administration