8/24/17
BOROUGH OF COLLEGEVILLE
ELECTRICAL CONTRACTOR REGISTRATION FORM
NAME OF COMPANY: ________________________________________________
ADDRESS: _________________________________________________________
____________________________________________________________________
Email: ______________________________________________________________
PHONE NO: ___________________________ FAX NO. ___________________
STATE OF PA. REGISTRATION NUMBER: ________________________________
INSURANCE CO:
____________________________________________________________________
INSURANCE AGENT:
____________________________________________________________________
I certify that the statements contained herein are true and correct to the best of my
knowledge and belief. I understand that if I knowingly make any false statements
herein, I am subject to the penalties as may be prescribed by law or ordinance.
APPLICANT:
______________________________________________________________________
Borough of Collegeville
491 E. Main Street
Collegeville, PA 19426
610-489-9208 610-489-6661 Fax www.collegeville-pa.gov
OFFICIAL USE ONLY
REG. NUMBER: ____________ STATE OF PA. REG. NUMBER: ___________
AMOUNT PAID: ______________________ CHECK NUMBER: ___________
DATE PAID: ______________________________________________________
DATE REGISTRATION CARD ISSUED: ________________________________
APPROVED _______________________________________________________
DATE: ___________________________________________________________
____________________________________________________
