Register as a Safe Installer/Technician

You must fill out all required fields.

Billing Address

Street Address(Required)

Suite #:

City(Required)

ZipCode:(Required)

Country:(Required)

State / Province / Region Country

Email Address:(Required)

An email is required.

Website URL(Required)

Phone Number(Required)

A phone number is required.

(Ext.)

FAX

Contact Name(Required)

Yes, I prefer you contact me.

Shipping Address

(if different from Billing)

Street Address:

Suite #:

City:

ZipCode:

Scope of work questionnaire

Do you perform locksmith services only?

Yes

Do you sale Safes?

Yes

Do you sale CCTV?

Yes

Do you install CCTV?

Yes

Do you have experience with Electronic & Combination Safe Locks?

Yes

Is your location equipped with a Loading Dock and/or Forklift?

Yes

Do you have a delivery truck with a lift gate?

Yes

If YES, please provide the maximum weight capacity:

lbs

Do you perform safe-opening?

Yes

Do you anchor safes?

Yes

Do you perform inside-delivery for safes?

Yes

If YES, please provide a list of the equipment used in handling different weights, sizes and vertical movement of safes, and flooring types that are presented in these challenging deliveries:

What is the maximum weight you are able to handle

lbs

Service Fees

Please select the service miles from your business location:

0-25

25-50

50-75

75-100

Service Information

Service Miles

Service Trip Fee

Hourly Labor Fee

Sales Tax

Please provide payment terms & conditions:

If hired by Mesa Safe Company, can you provide the following:

Certificate of Liability Insurance

Yes

Copy of ALOA Membership Card [if member]

Yes

Tax Payer ID Number & Certification [W-9]

Yes

SELECT PAYMENT TYPE

Payment by Check

Payment by ACH

Please choose how you would like to receive payment:

MESA SAFE COMPANY makes every effort to pay locksmiths, safe technicians and installers every 25 Days after job is complete and receipt of invoice. MESA SAFE COMPANY can pay your invoices via check or ACH [ACH = direct deposit into your bank account]. If you choose to receive payment by check there is no setup fee and payment is every 25 days. If you choose to be paid by ACH, there is a onetime setup fee of $15.00. A fee of $2.00 will be charged for every ACH transaction. If you choose to receive payment via ACH you will be paid every 15 days. Please provide the following information below if you choose payment by ACH.

Liability Release, Waiver of Claim & Confidentiality Statement & Agreement Please read carefully & complete all forms below I

(Company Name)

(Phone Number),

And our employee

Employee/Contractor Name, agree that I have been engaged by MESA SAFE COMPANY, to perform related services for them. Acting as an independent contractor and not as an employee of MESA SAFE COMPANY, I release MESA SAFE COMPANY from any claim that an employment relationship exists on any project performed for MESA SAFE COMPANY.

Our client(s), or contractors [Field Service Companies] shall not be responsible for damages, whether personal or property, incurred by

(Company Name) while providing services and materials for the MESA SAFE COMPANY projects.

(Company/Contractor) represents that he/she has adequate liability insurance coverage, including auto-mobile and worker’s compensation.

All services performed for MESA SAFE COMPANY are confidential services. I have read and understand that this Agreement requires that I do not discuss with, or disclose to anyone or any entity other than MESA SAFE COMPANY, any information that I learn from or as a result of, my involvement with MESA SAFE COMPANY. Furthermore, I understand that my obligations pursuant to this agreement shall continue even after I am no longer performing services for MESA SAFE COMPANY.

(Company name) agrees not to release or distribute any materials or information related to any services performed for MESA SAFE COMPANY. Upon completion, all service materials and paperwork must be returned to MESA SAFE COMPANY.

I understand that by signing this agreement, I am agreeing not to bring, encourage or participate in bringing any action, claim, charge or to commence any form of legal proceedings seeking recovery of damages against MESA SAFE COMPANY or their respective shareholders, owners, affiliates, employees, officers, directors, parents or subsidiaries, or any person acting in concert with any of them, while performing any of the Agreement will result in irreparable injury to MESA SAFE COMPANY and their affiliates, and that they are entitled to seek and obtain immediate injunctive relief prohibiting me from engaging in conduct contrary to this agreement

Check the box below to accept the terms & conditions of this application.

Once terms & conditions are accepted, your application will be electronically signed. To complete the application, select "SUMBIT".

Full Name(Required)

Date(MM-DD-YYYY):(Required)

By signing this document, MESA SAFE COMPANY, its clients and its contractors are released from such damages or liability.

Electronic Signature(Required)

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