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PLC:

a002vr

Agency:

village of ballston spa

For:

misc., fees

Phone:

518-885-5711

Address:

66 front street
ballston spa, new york 12020

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Middle:

*Last:

*Phone Number:

(### - ### - ####)

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Total:

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*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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