THE NEBRASKA LOCKSMITHS ASSOCIATION, INC.

APPLICATION FOR MEMBERSHIP

An organization of lock experts whose purpose is to better the locksmith profession by interchanging trade information, Mechanical knowledge and creating good fellowship among its members who are pledged to deal honestly in every branch of the business and to co-operate with the lock manufacturer and the user for the maintenance of the security in the mechanism of the locks entrusted to them for service by the public.

I understand the aims and purposes of the Nebraska Locksmiths Association, and I feel that I qualify as a member for the reasons stated below.

Full Name (First) (Last) (MI)

Address Phone # Fax # Email Address

City State Zip
Social Security Number Date of Birth
Place of Birth Sex Spouse's Name
Color of Hair Color of Eyes Height Weight
Have You Ever Been Arrested and Convicted of a Felony? If So, Give Details
Are Your Fingerprints On File At Your Local Law Enforcement Agency
Business Name

Business Address City State Zip Phone # Fax # Email

Do You Spend All Your Employable Time in the Locksmithing Field?
Do You Derive the Main Source of Your Income From the Locksmithing Field?

If not self employed, please answer the following:

Company OR Individual
City State Zip Phone
Your Supervisor's Name
In This Company, What is Your Position?
Do You Belong to any Other Locksmith Associations? If So Please List:
State the Approximate Year You Started in the Locksmithing Field
If A Resident of Nebraska or Do Work in this State, Please Give Your Locksmithing Registration Certificate Number County

Did You Attend Any School of Locksmithing?

Which One? Date Graduated

REFERENCES: Please list as many as possible, up to three for each category

LOCKSMITH REFERENCES:

Name Address
Name Address
Name Address

CHARACTER REFERENCES:

Name Address
Name Address
Name Address
Name and Title of Local Law Enforcement Body:
Do You Do Safe Work? Repair Door Closers? Or Any Other Type of Specialized Work?
Would You Be Willing to Interchange Trade Information and Mechanical Knowledge With Other Members of This Association?
Do You Keep and Maintain the Manufacturers Security and DO NOT Defeat the Intended Purpose in the Mechanism of a Lock?
Would You Take an Oath to Keep Restricted Information if Accepted?
Will You Abide by the Ethics Set Forth By the NE Locksmith Assn?

I certify that the above statements are true, and I acknowledge the fact that my application may be investigated before my membership is accepted.

LEGAL SIGNATURE ______________________ DATE___/___/___

THIS APPLICATION FOR MEMBERSHIP REQUIRES THE APPLICANT’S PRESENCE AT A MEETING OR A FUNCTION OF THE ASSOCIATION, BEFORE IT WILL BE ACTED UPON. _______________________________________________________________________________________

DO NOT WRITE IN THIS SPACE / RETURN APPPLICATION AND FEES

Membership number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ TO:

Application Mailed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ by _ _ _ _ _ _ _

Application Rec’d _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ by _ _ _ _ _ _ _

Application Accepted _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ by _ _ _ _ _ _ _

Fees Received _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ by _ _ _ _ _ _ _

Application Rejected _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ by _ _ _ _ _ _ _

$10.00 shall accompany this form for processing

(Dues are $35.00 per year due at acceptance prorated quarterly)

This is non refundable.

Nebraska Locksmith Association, INC.
Eugene Hansen (Editor 2006)

726 W 16th St

Alliance, NE 69301