D form to (360) 570-4961 or scan and email to interlock dol.wa.gov Driver PRINT or TYPE Driver name (Last, First, Middle initial) Date of birth Driver license number Mailing address City State ZIP code Activity Installation . . . . . . . . . . . . . . . . . . . . Date Compliant . . . . . . . . . . . . . . . . . . . . . Date Removal/Non-functioning . . . . . . . . . Date 4-month compliance release . . . . . . Date In the 4 consecutive months prior to this date th.
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How to fill out the WA DR-500-011 online
Filling out the WA DR-500-011 form is essential for ignition interlock companies to report ignition interlock activity accurately. This guide will help you understand each section of the form and provide step-by-step instructions to ensure a smooth completion process.
Follow the steps to complete the form with ease.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin with the 'Driver' section. Print or type the driver's name in the order specified: Last, First, Middle initial. Enter the driver's date of birth and driver license number.
- Fill out the 'Mailing address' section by providing the complete address, including city, state, and ZIP code.
- Move to the 'Activity' section. Here, you will report the dates for various activities: installation, compliance, removal/non-functioning, and the 4-month compliance release. Make sure to detail each date accurately.
- Indicate whether any incidents occurred in the last four consecutive months that could affect compliance. Review the list provided and ensure none of the incidents happened.
- Check the appropriate box to select the device type used from the options provided, such as AutoSense, Guardian, or others listed.
- Fill in the vehicle details, including make/model, year, vehicle identification number (VIN), and license plate number.
- Enter the device number associated with the ignition interlock device.
- Proceed to the 'Company' section. Print or type the ignition interlock company name and Washington business license number.
- Provide the name of the company representative and their telephone number, using the area code format.
- Lastly, fill in the company’s mailing address, including city, state, and ZIP code.
- Review all sections for accuracy and completeness. Once you are satisfied, save your changes, download, print, or share the completed form as needed.
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