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PLC:

a006ne

Agency:

ecollect plus

For:

upper darby township

Phone:

866-225-0033

Address:

804 fayette street
conshohocken, pennsylvania 19428

*Required Field

Payment Information

Instructions & Deadline: The following registration form is required to be completed by each company with a business location in Upper Darby Township or any business operating within the territorial boundaries of Upper Darby Township.

This Application is due for Business Privilege Tax and Mercantile Tax: January 31, 2025.

*Applicant Name:

Middle:

*Last:

*Legal Name of Business:

*Mailing Address:

*City:

*State:

*Zip:

*Email:

*Business Start Date:

(Month / Day / Year)

Trade Name (DBA):

*Physical Address:

*City:

*State:

*Zip:

Fax:

*Federal EIN:

*Business Location(s):

*Business Organization Type (check only applicable):

Sole Proprietorship

Partnership

Corporation or LLC

Service

Rental

Retail

Wholesale

*I hereby certify under the penalties provided by law that all statements made herein are to the best of my knowledge and belief true, correct and complete.:

Payment Amount

*Payment Type:

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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