Emergency Lockout Work Order

Authorization For Security / Emergency Services

  I hereby certifiy the information provided as required by California Penal Code SS466.6 and/or SS466.8 and California Business and Professions Code Chapter 8, Section 6980 is true and accurate to the best of my knowledge and that I have the authority to order and accept full legal responsibility for the lock, key or security work designated above, absolving the locksmith who bears this authorization from any and all claims arising from the performance of such work.

P.O. / Dispatch #: __________  Work-Order / Invoice #: ___________

Person's Name:__________________Member # _________

Call-Back Phone # (    ) _______________    Extension _____________

Home Address: _____________________________________________

Driver's License # __________________    D.O.B. _______________

Hair ________  Eyes ________  Height ________  Weight ________  Sex ____

Auto:       Dispatched By:    ___X Country    ___ERS    ___Private      Other____________

Dispatcher's Name __________________ Phone # ____________  Ext. _________

Address of Lockout: ________________________________________

Major Cross-Streets ___________________________________

Describe Location of Auto:  Parking Lot, Rear / Front, Driveway, On Street, Etc.

Door Key # _____________________  VIN # ____________________________

Year ________ Make ________________ Model ________________ Color ________

License Plate # ______________  State ___________  Registration # ____________________

Building: Address of lockout ______________________________________

Major Cross-Streets________________________________________________

Price Quoted $___________