Lock-Out Form

Date (required)

BWFR CR# (required)

I am the owner, or the legally empowered and authorized agent of the owner, of the vehicle listed below and do hereby authorize the Bennett Fire Protection District to use the tools and procedures necessary in order to gain access to the motor vehicle listed below. I agree to indemnify and hold the Bennett Fire Protection District harmless from any and all liability or damage done while attempting to, and in gaining access to the vehicle or other property as specified.

Vehicle Owner/Operator Name

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Personal Information

Street Address (required)

City (required)

State (required)

Zip Code (required)

Email Address (required)

Driver's License Number (required)

Driver's License State (required)

Expiration (required)

Vehicle Information

Year (required)

Make (required)

Model (required)

License Plate (required)

State (required)

VIN (required)

BWFR OFFICIAL USE ONLY

Officer Name

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Witness Name

Attachments

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