DL-21SC (4-18) Email Form To [email protected] Violation occured prior to 10/1/03 PRINT NAME PRINT NAME date installed I certify that all information given on this statement is true and correct. E. CUSTOMER INSTRUCTIONS FOR COMPLETING THIS FORM

Act 33 of 2016 created the Ignition Interlock Limited License. This license is for those whose driving privileges are suspended or revoked due to DUI violations or refusing chemical tests. It allows them to drive cars with Ignition Interlock systems, if they meet certain conditions.

List all vehicles that you own or that you have permission to drive. The title #, tag #, VIN #, and make of vehicle can be found on the registration card. The vendor will verify the information that you supply. You may be required to show current registration and proof of insurance.

Where does an individual obtain a ‘Self-Certification of Vehicle(s)’ form (DL-21SC), Hardship Exemption form (DL-21SC), or Employment Exemption Form (DL-3805)?

This form is to be completed when you are requesting to have an Ignition Interlock system(s) removed from a vehicle(s) other than the vehicle(s) you have chosen to operate during your required one-year II period.

You must contact an Approved Ignition Interlock Vendor and request a DL-21SC for Non-ownership. You must Complete Section A, B and sign section C and provide the form to the Ignition Interlock Vendor so they can complete the vehicle registration check to verify that you do not own a vehicle.

List all vehicles that you own or that you have permission to drive. The title #, tag #, VIN #, and make of vehicle can be found on the registration card. The vendor will verify the information that you supply. You may be required to show current registration and proof of insurance.

List all vehicles that you own or that you have permission to drive. The title #, tag #, VIN #, and make of vehicle can be found on the registration card. The vendor will verify the information that you supply. You may be required to show current registration and proof of insurance.

DL-21 Certification. It is possible to have your Driver's License Restored without owning a vehicle in the State of Pennsylvania. This is possible by completing a DL21 Certification that you own no vehicles in the state. Once you have your privilege restored, we can also help you by installing an ignition interlock. What if I Don't Own a Car?

List all vehicles that you own or that you have permission to drive. The title #, tag #, VIN #, and make of vehicle can be found on the registration card. The vendor will verify the information that you supply. You may be required to show current registration and proof of insurance.