BOROUGH OF COLLEGEVILLE
MECHANICAL CONTRACTOR REGISTRATION APPLICATION
NAME OF COMPANY: __________________________________________________
ADDRESS: ___________________________________________________________
_____________________________________________________________________
PHONE NO: _______________________ FAX NO. _________________________
EMAIL: ______________________________________________________________
PA REGISTRATION NO: ________________________________________________
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 penalties as may be
prescribed by law or ordinance.
APPLICANT SIGNATURE: _______________________________________________
OFFICIAL USE ONLY
REG. NUMBER: __________________ AMOUNT PAID: ___________________
CHECK NUMBER: ________________ DATE PAID: ______________________
DATE REGISTRATION CARD ISSUED: ________________________________________
APPROVED BY: ___________________________________________________________
DATE: ___________________________________________________________________
Borough of Collegeville
491 E. Main Street
Collegeville, PA 19426
610.489.9208 610.489.6661 (fax) www.collegeville-pa.gov
OFFICIALUSEONLY
REG.NUMBER:_________________STATEOFPAREG.NUMBER:______________________
AMOUNTPAID:________________CHECKNUMBER:________________________________
DATEPAID:___________________DATEREG.CARDISSUED:_________________________
APPROVEDBY:______________________________________________________________________
DATE:_____________________________________________________________________________
