How to contact Us - Charles J. Poliero, Inc.

How To Contact Us

By Phone:	(Office)
By Fax:	(Fax)
By e-mail:
Address:	Charles J. Poliero, Inc. 316 White Horse Pike, Suite 100; Camden County Collingswood, NJ 08107-1943

General Information Form

If you are an owner, please complete Sections 1, 2, 3, 4 and 6
If you are a tenant, please complete sections 2, 3, 4, 5, and 6
Indicate address of the leased premisis

Once this form is completed, if there is any change in the
information on this census form it is to be reported to Charles J.
Poliero within thirty business days of the change.

1-Owner General Information Form

*Name/Owner:
*Address of Leased Property:
*Mailing Address of Owner:
*Home Phone:
Work Phone:
Cell Phone:
*Email Address:

1a-Emergency Contact for Owner

*Name:
*Phone:
*Relationship:

2-If you are a tenant, fill out the following

*Home Phone:
Work Phone:
Cell Phone:
*Email:

2a-Emergency Contact for Tenant

*Name:
*Phone:
*Relationship:

3-For Rented Properties, List Occupants

Occupant:
Relationship:
Birth Date (If under 18 years old, only):
Occupant:
Relationship:
Birth Date (If under 18 years old, only):
Occupant:
Relationship:
Birth Date (If under 18 years old, only):

4-List of vehicles you will park on the property

Make/Model:
Year:
Color:
License Plate # and State:
Make/Model:
Year:
Color:
License Plate # and State:
Make/Model:
Year:
Color:
License Plate # and State:

5-Information for pets, which reside on property

Type of Pet:
Breed:
Color/Markings:
Pets Name:
Type of Pet:
Breed:
Color/Markings:
Pets Name:

6-Additional Information that is helpful to us

Additional Information:

Personal Information

Name:
Electronic Signature (retype name):
Date:

Note: Fields with an * are required

Charles J. Poliero, Inc. 316 White Horse Pike, Suite 100 Camden County Collingswood, NJ 08107-1943

Phone: Fax: