AutoCode Sign Up Form https://www.autocode.us/signup/signup.

php

AutoCode
Key Codes Access Application Brooklyn, NY
11230

Please print the document, sign the fields marked with red arrows, and fax it to (855) 258-9014 or
email it to support@autocode.us .

If for some reason you cannot fax or scan the document please contact us at
support@autocode.us .

All the information provided will be verified and we will send you an email confirmation after your
background check has been completed and all documents have been processed.

Please allow up to 6 business days for approval. After the approval you will be emailed a username and
password for the app and website.

COMPANY NAME (mm587125)

COMPANY

INFORMATION
AutooloungeSA

ADDRESS CITY STATE ZIP

43578 Momri str Tsakane NONUS 1550

OFFICE PHONE CELL PHONE FAX

27835507787 1

EMAIL ADDRESS TAX ID # LOCKSMITH LICENSE

autolounge@gmail.com 1 1

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OWNER NAME DRIVER’S

1
Mbongiseni Mdakane LICENSE &

STATE

1-1

Company Owner - Please print and sign next to each red arrow, and fill out the information next to
each blue arrow:

DATE
INITIALS
TERMS & The key codes and information I receive are for use within the stated company and will
Feb 17th, not be sold or given to anyone outside of my company.
CONDITIONS
2023

DATE
INITIALS
I will use the information I receive from AutoCode Inc in a lawful manner.
Feb 17th,
2023

DATE
INITIALS
I hereby agree to absolve, defend, indemnify and hold harmless: the owners,
Feb 17th, management, employees, subcontractors, and affiliates of AutoCode Inc from any
2023 and all claims arising from the authorized or unauthorized use of the requested,
specified and acknowledged services described herein.

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DATE
INITIALS I declare that I am requesting vehicle information on behalf of my customer and I will
Feb 17th, examine their driver’s license and either title or registration to prove they are the vehicle
2023 owner.

DATE
INITIALS
I will not retain any codes obtained from AutoCode Inc after services are completed.
Feb 17th,
2023

DATE
INITIALS
I understand that a violation of this agreement will terminate my business relationship
Feb 17th,
with AutoCode Inc.
2023

I am acknowledging and giving permission to AutoCodeto run a background check on myself, my company and any
individuals associated with the accessing of key code information. I do solemnly swear, affirm, and promise under
criminal penalty of a felony for fraudulent use of a false or fictitious name or address or for making a false material
statement punishable by fines of up to $10,000 or by imprisonment of up to five years, or both, that the statements
contained herein are true and accurate. A violation of any part of this agreement will cause the termination of
business relations with AutoCode. I understand that phone conversations with AutoCode may be recorded for security
purposes.
PRINT NAME

Mbongiseni Mdakane

SIGNATURE DATE

Feb 17th, 2023

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Employer & Employee Statement (after you print, fill out the information next to the blue arrow and
sign next to the red arrow)

COMPANY NAME
COMPANY

INFORMATION
AutooloungeSA

ADDRESS CITY STATE ZIP

43578 Momri str Tsakane NONUS 1550

As the employer, I hereby agree to oversee and take responsibility for the proper use of any key codes given to my
company.
PRINT NAME

Mbongiseni Mdakane

SIGNATURE DATE

Feb 17th, 2023

EMPLOYEE EMPLOYEE NAME

INFO
Mbongiseni Mdakane

PHONE DRIVER’S LICENSE & STATE LOCKSMITH LICENSE

27835507787 1-1 1

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AutoCode Sign Up Form https://www.autocode.us/signup/signup.php

Employee - Please print and sign next to each red arrow, and fill out the information next to each blue
arrow:

DATE
INITIALS
TERMS & The key codes and information I receive are for use within the stated company and will
Feb 17th, not be sold or given to anyone outside of my company.
CONDITIONS
2023

DATE
INITIALS
I will use the information I receive from AutoCode in a lawful manner.
Feb 17th,
2023

DATE
INITIALS
I hereby agree to absolve, defend, indemnify and hold harmless: the owners,
Feb 17th, management, employees, subcontractors, and affiliates of AutoCode from any and
2023 all claims arising from the authorized or unauthorized use of the requested, specified
and acknowledged services described herein.
DATE
INITIALS I declare that I am requesting vehicle information on behalf of my customer and I will
Feb 17th, examine their driver’s license and either title or registration to prove they are the vehicle
2023 owner.

DATE
INITIALS
I will not retain any codes obtained from AutoCode after services are completed.
Feb 17th,
2023

DATE
INITIALS
I understand that a violation of this agreement will terminate my business relationship
Feb 17th,

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AutoCode Sign Up Form https://www.autocode.us/signup/signup.php

2023 with AutoCode.

I am acknowledging and giving permission to AutoCode Incto run a background check on myself, my company and
any individuals associated with the accessing of key code information. I do solemnly swear, affirm, and promise under
criminal penalty of a felony for fraudulent use of a false or fictitious name or address or for making a false material
statement punishable by fines of up to $10,000 or by imprisonment of up to five years, or both, that the statements
contained herein are true and accurate. A violation of any part of this agreement will cause the termination of
business relations with AutoCode. I understand that phone conversations with AutoCode Inc may be recorded for
security purposes.
PRINT NAME

Mbongiseni Mdakane

SIGNATURE DATE

Feb 17th, 2023

Trade References:

COMPANY NAME CONTACT NAME PHONE ACCOUNT #

TRADE

REFERENCES
ADDRESS CITY STATE ZIP DATE ACCT ESTABLISHED

//

COMPANY NAME CONTACT NAME PHONE ACCOUNT #

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ADDRESS CITY STATE ZIP DATE ACCT ESTABLISHED

//

COMPANY NAME CONTACT NAME PHONE ACCOUNT #

ADDRESS CITY STATE ZIP DATE ACCT ESTABLISHED

//

Credit Card Authorization:

AUTHORIZATION I hereby authorize AutoCode Inc to automa�cally charge the credit card ending with 5513 as needed
for every code generated by the AutoCode service. A detailed statement will follow via email or fax
number provided. I also agree to abide by the condi�ons set forth in the card issuer’s agreement.
In the event of li�ga�on rela�ng to the subject ma�er of this Agreement, the non-prevailing party
shall reimburse the prevailing party for all reasonable a�orney fees and costs

SIGNATURE PRINT NAME DATE

Mbongiseni Mdakane Feb 17th,

2023

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