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PLC:

7982

Agency:

village of edgar

For:

invoices

Phone:

715-352-2891

Address:

224 south third ave,p o box 67
edgar, wisconsin 54426

*Required Field

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*Name:

Middle:

*Last:

Street Address:

*Invoice #:

Daytime Contact #:

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

Payment Amount

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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