Application for Contractor's License

Code Enforcement Department

Business Information

Pursuant to Ordinance #925 hereby apply for Contractor's License in the Township of Springfield and I submit the following statement.

Firm Name *

Office Phone Number *

Cell Phone Number *

Firm Address *

City *

State *

Zip *

Business Type *

Entity Type *

Number of Years in Business *

Employer Identification Numbers

City

State

Federal

Phila. Mercantile License No.

Licensed in Other Municipality as a Contractor *

Yes No

	Location	Date Licensed
1	Location	Date Licensed

Location

Date Licensed

Export Clear Add new row

1

Location

Date Licensed

Insurance Information

Public Liability Insurance

Liability Carrier

Liability Policy Number

Amount

Workman's Compensation Insurance

Carrier

Policy Number

Agent

Agent Phone Number *

Policy Start Date

Policy End Date

Worker's Compensation Information

The Applicant is a Contractor within the Meaning of the Pennsylvania Worker's Compensation Law

Yes No

Insurance Information

Applicant Name *

Federal or State Employer ID No. *

Applicant is a Qualified Self-Insurer for Worker's Compensation? *

Yes No

Upload Certificate

Upload

Name of Workers' Comp Insurer

Insurance Policy Number

Policy Expiration Date

Upload Policy Certificate

Upload

Exemption

Complete this section if the applicant is a contractor claiming exemption from providing worker's compensation insurance.

The undersigned swears or affirms that he/she is not required to provide worker's compensation insurance under the provisions of Pennsylvania's Worker's Compensation Law for one of the following reasons, as indicated:

Contractor with no employees

Religious exemption under the Worker's Compensation Law

Applicant Information

List here the Names of Owners, Partners, Directors and Officers of the Business

Applicant Name *

Applicant Official Title *

Home Address *

City *

State *

Zip Code *

County *

Phone Number *

Previous License Num.

Year

Have Complaints Against You Ever Been Filed with the Better Business Bureau or the Consumer Protection Agency? *

Yes No

Do You Agree to Confirmation of the Above with the Better Business Bureau or Other Agencies? *

Yes No

I hereby 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 statement herein I am subject to such penalties as may be prescribed by law or ordinance.

We authorize you to obtain any information that you require concerning statements in this application, which shall remain the property of Springfield Township.

Name *

Title *

Applicant Email Address *

Required Fee

Authorized Signature (Use the Drawing Tool to Sign in the Box)

Payment of fees for this application will be requested via email once your submission has been reviewed.  Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.

Submit Payment

Payment of fees for this application will be requested via email once your submission has been reviewed.  Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.  The amount shown below is an estimated amount and may be adjusted once your submission is reviewed.

Payment Amount Due

Application for Contractor's License

Code Enforcement Department

Business Information

Employer Identification Numbers

Insurance Information

Public Liability Insurance

Workman's Compensation Insurance

Worker's Compensation Information

Insurance Information

Exemption

Applicant Information

Submit Payment

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