Ignition Interlock Device Approval Application

Ignition Interlock Device Approval Application Ignition Interlock Device Approval Application Section 1 – Manufacturer Information Full legal name (entity that manufactures the ignition interlock device model submitted for approval) Physical address (entity that manufactures the ignition interlock device model submitted for approval) ________________________________________________________________________________ Mailing address (entity that manufactures the ignition interlock device model submitted for approval) ____________________________________ ___________________________________ Manufacturer entity telephone number Manufacturer entity fax number Manufacturer web address Section 2 – Manufacturer Representative/Vendor ___________________________________ ________________________________ Name of Manufacturer Representative Title ______________________________________ ___________________________________ Telephone number E-mail address Section 3 – Certification Certification is requested by the Department of Public Safety for the following ignition interlock device: Ignition Interlock Device Manufacturer Name, Model and Version (list camera if applicable) Source: Miss. Code Ann. § 45-1-3 Section 4 – Required Items □Completed application for certification □Administrative fee attached. A certified check, cashier’s check or money order in the amount of $1000.00 made payable to the Department of Public Safety. □A notarized affidavit from a testing laboratory that includes: □The name of the laboratory □The address and telephone number of the testing laboratory □A copy of the applicable accreditation certificate for the testing laboratory □A description of all anti-circumvention features to be used in Mississippi □The Quality Assurance Plan created in accordance with the most current National Highway Traffic Safety Administration (NHTSA) Model specifications for Breath Alcohol Ignition Interlock Devices (BAIID) 78FR 26862 (2013-05-08) □Certificate of insurance issued in accordance with MS DPS requirements Section 5 – Signature and Date My signature below, certifies, the information given in this application and all accompanying documents is true and correct to the best of my knowledge and ability. __________________________________ _________________________ Manufacturer Representative‘s signature Date DO NOT WRITE BELOW THIS LINE Reviewed by ____________________________________ Date ______________________ □Approved □Denied Manufacturer series number_________________ Reviewer’s Comments_______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ MISSISSIPPI DEPARTMENT OF PUBLIC SAFETY TITLE 31: PUBLIC SAFETY PART 505: CRIME LAB – IGNITION INTERLOCK DEVICE PROGRAM Part 505 Chapter 1 Purpose and Scope