The Lock Doctor, Inc.

The undersigned is applying for credit with The Lock Doctor, Inc., and agrees to abide by the terms and conditions of  The Lock Doctor, Inc. standard contract.

1.  Company Name and Address









2.  Phone (     )


Fax (     )


3. Federal Tax ID or Social Security No.


4.  Type of Business


No. of Employees


5.  Date Business Established


6.  Types of Products You Will Purchase


7.  Amount of Credit Requested $


8.  Check which is applicable to you:

o Corporation

o General Partnership

o Limited Partnership


o Sole Proprietorship

o Other :  _________________

9.  State where your company was organized :


10.  Have you or any of your affiliates ever had credit with us before or purchased from us before?  Yes ___  No __

If yes, under what name?


11. Name or title of persons authorized to act on your behalf :


12. Trade References

Reference #1 Name and Address :







Phone (      )


Reference #2 Name and Address :







Phone (      )


13. Bank References

Bank #1 Account #


Phone (      )


Contact Person


Name of Bank




Bank #2 Account #


Phone (      )


Contact Person


Name of Bank




14. Financial Information about your Company :

Assets :                       $



Liabilities:                  $



Approximate Annual
Net Income:                $



15. Have you or your officers or affiliates ever filed a petition in bankruptcy?


16. Are you subject to any litigation?


If so, describe here :






17. Are you current in meeting your other financial obligations?


We declare that the above information is true, correct and complete and is given to induce the Company to extend credit.  We authorize the Company to make such credit investigation as the Company sees fit, including contacting the above trade references and banks and obtaining credit reports.  We authorize all trade references, banks and credit reporting agencies to disclose to the Company any and all information concerning the financial and credit history of my company and myself:

I have read the terms and conditions stated below and agree to all of those terms and conditions

Name of Company


Authorized Signature :


Printed Name :


Title :


Date :



1.       All bills become payable in full 30 days after receipt.  If not paid by such time, bills are considered past due. A service charge of 5% per monthly will be added to all amounts billed if not paid by the end of the month, together with interest at the rate of 1½% per month.

Please forward this information to…..

The Lock Doctor, Inc. 310 N.E. 291 Highway, Lee’s Summit, MO. 64086

816-525-5522           Fax 816-525-8628
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