Fillable PA 09-144 REGISTRATION FORM Please Complete and Sign

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PA 09-144 REGISTRATION FORM Please Complete and Sign

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PA 09-144 REGISTRATION FORM
Please Complete and Sign form.
Filing fee: $100.00. Payable to town of registration.
Vacant Property Address: ________________________________________
Registrant/Owner: _____________________________________________________________
Mailing address: _______________________________________________________________
City: _______________________________________ State: __________ Zip: ____________
Email: _________________________________________________________________________
Prefer to be contacted by (check one): U.S. Mail ________ Email: ________
Phone: ________________________________ Fax: ________________________________
If the above is a Corporation or Out-of-State Registrant –
please list in-state contact information below:
Company/Contact: ____________________________________________________________
Mailing address: _______________________________________________________________
City: _______________________________________ State: __________ Zip: ____________
Email: ________________________________________________________________________
Phone: ________________________________ Fax: ________________________________
Property Maintenance/ Management Company (if applicable)
Company/Contact: ____________________________________________________________
Mailing address: _______________________________________________________________
City: _______________________________________ State: __________ Zip: ____________
Email:_________________________________________________________________________
Phone: ________________________________ Fax: ________________________________
REGISTRANT’S SIGNATURE:_________________________________________________
Print Name:
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PA 09-144 REGISTRATION FORM Please Complete and Sign

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Completed 13 May 2021

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