LOST COMBINATION FORM



I, _____________________________________, being duly sworn, say I am the owner of the
  (Print Full Name)

Master Lock® padlock with the serial number ____________________________.
(Serial Number)
     
  *NOTE: You must attach a photocopy or digital image of the back of the padlock with this form.
     
  Please place an "X" next to your preferred method of delivery:

  My lock combination should be sent to:
  •   Please note, providing an email address will expedite the
    receipt of your combination request.
checkbox ________________________________________
  (Email Address)
checkbox ________________________________________
  (Street Address)
  ________________________________________
  (City, State, Zip Code)
   
     
________________________________________
(Signature)
     
  STATE OF __________________________________
  COUNTY OF __________________________________
  Sworn to and subscribed before me
  this _______ day of _______, 20___
  My commission expires on:
  ________________________________________
  ________________________________________
  (Notary Public)