Please allow 2 business days to receive your response.Please ensure that all of the below information is accurate. Information that is incomplete, or not accurate, will cause delays in the processing of your appointment.All fields marked with an asterisk (*) are mandatoryAre you a New Client or a Transitioning Client?*New participant to the programTransitioning participant from a different supplierNOTE: Transitioning clients currently have an Ignition Interlock device installed on their vehicle and are planning to transfer their program to Smart Start.Letter of Eligibility from SAAQ*Yes, I have it and I will bring it to my appointmentNo, I did not receive it yetWe cannot proceed with the creation of your file and you will not be able to submit this form. Please contact us upon receiving your Letter of Eligibility from the SAAQ.Do you have a removal appointment?*Yes, I have a removal appointment. See below.No, I do not have a removal appointmentRemoval Date* Date Format: YYYY dash MM dash DD Removal Time*Hour12356789101112 Minute000510152025303540455055 AMPMWe cannot proceed with the creation of your file and you will not be able to submit this form. Please contact us when your removal appointment has been scheduled.What is or what will be the condition of your driver’s licence?You will find this information on your driver’s licence (participant in transition) or on your eligibility letter from SAAQ (new participant)RestrictedCondition ICondition XCondition ICAPersonal InformationFirst Name*Middle NameLast Name*Date of Birth* Date Format: YYYY dash MM dash DD Telephone Number*Alternate Phone NumberCan we send you information and notifications via text message?* Yes, I authorize you to send me text messagesEmail Address* Driver's License Number*Emergency Contact Name*Emergency Phone Number*AddressStreet Address*City/Town*ProvinceQuébecAlbertaBritish ColumbiaManitobaSaskatchewanCountryPostal Code*InstallationPreferred Service Centre*-- Select --AB, Barrhead - 4921 50 AveAB, Brooks - 618 Alberta Street WAB, Calgary - 113, 10555 48 St SEAB, Calgary - 4638 11 St NEAB, Camrose - 3720 48 AvenueAB, Cold Lake - 5611 54 StreetAB, Drumheller - 801 S Railway AveAB, Edmonton - 17518 105 Ave NWAB, Edmonton - 2683 96 St NWAB, Edson - 5101 3rd AveAB, Fort McMurray - 10017 Queen StreetAB, Grande Prairie - 11101 100 StAB, Hayter - 208 Armour AvenueAB, High River - 1008 20 ST SEAB, Hinton - 24503 East River RoadAB, Lethbridge - B 3015 12 Avenue NAB, Lloydminster - 5708 50 AveAB, Medicine Hat - 16 Strachan CRT S.E.AB, Peace River - Bay1, 8909 – 96 StreetAB, Red Deer County - 108-172 Clearview DriveAB, Sherwood Park - Unit 192 2301 Premier WayAB, Slave Lake - 621 Main Street NEAB, Whitecourt - 3708 Kepler St.BC, 100 Mile House - 916 Alpine Ave.BC, Abbotsford - 2602 Mount Lehman RdBC, Burnaby - 5589 Byrne Road, Unit 131BC, Campbell River - 250 Dogwood St Unit 108BC, Castlegar - 1965 Columbia Ave., Unit #200BC, Chilliwack - 7677 Prest RoadBC, Courtenay - 2885 Cliffe AveBC, Cranbrook - 1617 Cranbrook St NBC, Duncan - 170 TRANS CANADA HWYBC, Fort Nelson - 4444-50th AveBC, Fort St. John - 10920 - 100th Ave Fort St JohnBC, Golden - 1025 10th Ave NBC, Kamloops - 745 Notre Dame DrBC, Kelowna - 1881 Harvey AveBC, Langley - 20111 Industrial Ave. Unit #101BC, Maple Ridge - 470 20170 Stewart CrescentBC, Nanaimo - 201 - 3300 Norwell DrBC, North Vancouver - 150 Pemberton Ave. NBC, Penticton - 2601 Skaha Lake Road Unit 101BC, Port Coquitlam - 223-1655 Broadway StBC, Prince George - 2591A Vance RoadBC, Prince Rupert - 601 3rd Ave WBC, Quesnel - 855 Rita RoadBC, Richmond - 5400 Minoru BlvdBC, Sechelt - 102-5520 Sechelt Inlet CresBC, Terrace - 4716 Keith AvenueBC, Vancouver - 8770 Ash StreetBC, Vernon - 3107 48th Ave Unit 200BC, Victoria - 1681 A Old Island HighwayBC, Westbank - 2180 Elk Rd Unit 200BC, Whistler - 1330 Alpha Lake RoadBC, Williams Lake - 1148 Broadway Ave SMB, Blumenort - 9 Centre AveMB, Brandon - 121-17th St NorthMB, Dauphin - 55 Keays StreetMB, Flin Flon - MB-10 AltMB, Thompson - 91a Kelsey BayMB, Winkler - 545 Cargill RoadMB, Winnipeg - 1200 Fife StreetMB, Winnipeg - UnitA 1420 Clarence AvenueMB, Winnipeg - 615 Mission StreetQC, Acton Vale - 1124 Rue BoulayQC, Alma - 2685 Avenue du Pont SudQC, Amos - 91 Rue Principale SudQC, Baie-comeau - 930 Rue ComtoisQC, Beloeil - 276 Boulevard Sir-Wilfrid-LaurierQC, Blainville - 1444-A Boulevard Curé-LabelleQC, Boucherville - 1580 Boulevard de MontarvilleQC, Bromont - 1 Chemin des CarrièresQC, Brossard - 6135 Boulevard TaschereauQC, Brownsburg-chatham - 260 Rue des ÉrablesQC, Cap-aux-meules - 375 Chemin OscarQC, Chambly - 965 Boulevard de PérignyQC, Chateauguay - 315 Boul. IndustrielQC, Chibougamau - 581 3e RueQC, Chicoutimi - 985 Rue ChabanelQC, Cowansville - 360 rue RivièreQC, Dolbeau-mistassini - 283 8e AvenueQC, Drummondville - 1250 Boulevard LemireQC, Fermont - 451 Rue Le CarrefourQC, Gaspe - 164 Boulevard de GaspéQC, Gatineau - 801 Boulevard Maloney EstQC, Gatineau - 495 St-René Est, Unité 8QC, Granby - 1015 Rue PrincipaleQC, Granby - 1160 Rue PrincipaleQC, Jonquiere - 3320 Boulevard St-FrancoisQC, L'ancienne-lorette - 6007 Boulevard Wilfrid-HamelQC, La Baie - 2005 Boulevard de la Grande Baie NordQC, La Malbaie - 1950 Boulevard de ComportéQC, La Sarre - 289 2e rue EstQC, La Tuque - 947 Boulevard DucharmeQC, Lasalle - 1870 Avenue DollardQC, Laval - 1650 Boulevard des LaurentidesQC, Laval - 20 Boulevard Cartier OuestQC, Laval - 1740 Boulevard Curé-LabelleQC, Les Escoumins - 379 Route 138QC, Levis - 4505 Boulevad Guillaume-CoutureQC, Levis - 72 Route du Président-KennedyQC, Longueuil - 1055 Boulevard Curé-Poirier OuestQC, Longueuil - 2425 Chemin de ChamblyQC, Magog - 2572 Rue SherbrookeQC, Matane - 484 Avenue du Phare EstQC, Matane - 1650 Avenue du Phare OuestQC, Mercier - 1-200 Boulevard St-Jean-BaptisteQC, Mercier - 2-200 Boulevard Saint-Jean-BaptisteQC, Mirabel - 14036 Boulevard Curé-LabelleQC, Mirabel - 11365 Montee Ste-Marianne, suite 300QC, Mont-laurier - 1212 Boulevard Dr. Albiny-PaquetteQC, Mont-saint-hilaire - 733 Boulevard Sir-Wilfrid-LaurierQC, Mont-tremblant - 354 Rue Magloire GosselinQC, Montreal - 3255 Crémazie EstQC, Montreal - 4100 Rue Jarry EstQC, Nantes - 2737 Rue LavalQC, Notre-dame-des-prairies - 275 Boulevard Antonio-BarretteQC, Papineauville - 205 Rue Henri BourassaQC, Pierrefonds - 14301 Boulevard PierrefondsQC, Pointe-a-la-croix - 56 Boulevard InterprovincialQC, Pointe-aux-trembles - 12255 Rue Sherbrooke EstQC, Quebec - 13044 Boulevard Henri-BourassaQC, Quebec - 1798 rte de l'AéroportQC, Quebec - 800 Boulevard Charest OuestQC, Quebec - 265 rue SeigneurialeQC, Quebec - 5590 Rue des TenaillesQC, Repentigny - 332 Rue Notre-DameQC, Rimouski - 458 Boulevard Saint-Germain OuestQC, Rimouski - 55 Boulevard Ste-AnneQC, Riviere-du-loup - 262 Rue TemiscouataQC, Roberval - 488 Boulevard MarcotteQC, Rouyn-noranda - 669 Boulevard de l’UniversitéQC, Saint-apollinaire - 312 Rue LaurierQC, Saint-augustin-de-desmaures - 3587 Rue de L'HêtrièreQC, Saint-constant - 92 Rue Saint-PierreQC, Saint-eustache - 461 Boulevard Arthur-SauvéQC, Saint-felicien - 995 Boulevard HamelQC, Saint-georges - 9045 Boulevard LacroixQC, Saint-hyacinthe - 2995 Rue DessaullesQC, Saint-hyacinthe - 2530 Boulevard Laurier EstQC, Saint-jean-port-joli - 452 Route de l'ÉgliseQC, Saint-jean-sur-richelieu - 175 Boulevard Saint-LucQC, Saint-jean-sur-richelieu - 470 Boulevard Séminaire NordQC, Saint-jerome - 964 Rue LabelleQC, Saint-laurent - 2600 Boulevard PitfieldQC, Saint-malachie - 1204 Route HendersonQC, Saint-raymond - 599 Côte-JoyeuseQC, Saint-sauveur - 2252 Chemin Jean-AdamQC, Sainte-adele - 1386 Boulevard de Ste-AdèleQC, Sainte-agathe-des-monts - 1360 Rue Principale EstQC, Sainte-anne-des-monts - 457 Boulevard Sainte-Anne OuestQC, Sainte-catherine - 4400 Route 132QC, Sainte-julie - 1400 Rue Principale, local 201QC, Sainte-julienne - 2065 route 125QC, Sainte-marie - 1029 Boulevard Vachon NordQC, Salaberry-de-valleyfield - 1765 Boulevard Monseigneur-LangloisQC, Schefferville - 168 Rue des MontagnaisQC, Sept-iles - 646 Boulevard LaureQC, Shawinigan - 10133 Boulevard des HêtresQC, Sherbrooke - 1685 Rue DenaultQC, Sherbrooke - 4255 Boulevard BourqueQC, Sherbrooke - 2700 Rue King O, Local 2QC, Sherbrooke - 1091 13e Avenue NordQC, Sorel-tracy - 1760 Boulevard FisetQC, Temiscouata-sur-le-lac - 704 Rue Commerciale NordQC, Terrebonne - 1989 Chemin GasconQC, Thetford Mines - 970 Boulevard Frontenac OuestQC, Trois-rivieres - 1180 Boulevard ThibeauQC, Trois-rivieres - 5250 Boulevard Jean-XXIIIQC, Trois-rivieres - 6085 Boulevard Gene-H.-KrugerQC, Val-d'or - 1150 Rue de l'EscaleQC, Vaudreuil-dorion - 711 route Harwood Local 120QC, Victoriaville - 1010 Boulevard Jutras EstQC, Victoriaville - 900 Rue Notre-Dame EstSK, Estevan - 722 5th StreetSK, La Ronge - 704 Finlayson StreetSK, Laflèche - SK-13SK, Meadow Lake - 302 3 St ESK, Moose Jaw - 365 River Street West, Unit 133SK, North Battleford - 1731 100th StreetSK, Prince Albert - 524 B, 16 Street WestSK, Regina - 4X1, 156 1 Ave ESK, Saskatoon - 825 46th St ESK, Swift Current - 127 8 Avenue North WestSK, Yorkton - 465 Broadway Street EastPlease refer to the locations page for a visual geographical reference.Preferred Installation DateIt is important that you allow a minimum of two (2) business days to obtain an appointment through this form. The appointment must be confirmed by our Service center and may differ from your requested date. No appointment on Saturdays may be scheduled through this form. Date Format: YYYY dash MM dash DD MorningAfternoonConditionsWhat is your arrest date?* Date Format: YYYY dash MM dash DD Where have you been sentenced?*What is the length of your term?*Vehicle InformationVehicle Year*Vehicle Make*Vehicle Model*Vehicle Start Type*-- Select --Push ButtonTurn KeyVehicle Colour*Vehicle Identification Number (VIN)*License Plate Number*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
