Application For Collection Agency Registration

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For Office Use Only

File Number ________________________

State of Utah

This form must be type written or computer generated.

DEPARTMENT OF COMMERCE

Non-Refundable Processing Fee:

Division of Corporations & Commercial Code

[

] Registration

$32.00

Application for Collection Agency Registration

[

] Renewal

$32.00

Link to Guide Sheet

Print Form

Clear Form

1. Registered business name: ____________________________________________________________________

2. Business street address: ______________________________________________________________________

Street Address

______________________________________________________________________

City

State

Zip

3. Date business formed or incorporated: ___________________________

4. Name of the principal applicant-owner of the agency or authorized officer of the corporation:

_________________________________________________________________________________________

5. Principal's Address: _________________________________________________________________________

Street Address

_________________________________________________________________________

City

State

Zip

6. All applications must include original surety bond written for 1 (one) year. *If a collection agency is involved

with collecting payments from consumer credit transactions, please contact the Department of Financial

Institutions at (801)538-8830 regarding requirements.

7. I will faithfully comply with all provisions of the federal Fair Debt Collections Practices Act and consent to

have my agency registration canceled by the Division and shall forfeit my surety bond should I or my agency

be found to have violated the provisions of this Act in any material way.

I, _______________________________________ do swear,

Principal Applicant

under penalty of perjury, that the above information is true and complete.

Applicant must sign here after the form is printed

_____________________________________

_________________________

Signature of Applicant

Date

Where to file: You may file in person, or by mail. Means of payment are: cash, check, or money

This form must be filed in person or via the mail, along with the non-refundable $32 processing fee.

order. Non-refundable processing fee of $32.00.

Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, the business

entity physical address may be provided rather than the residential or private address of any individual affiliated with the entity.

Mail In: PO Box 146705

Mailing/Faxing Information:

Division's Website:

Salt Lake City, UT 84114-6705

Walk In: 160 East 300 South, Main Floor

Information Center: (801) 530-4849

Toll Free: (877) 526-3994 (within Utah)

Fax: (801) 530-6438