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PLC:

a002y7

Agency:

city of hallock

For:

utilities

Phone:

218-843-2737

Address:

163 south 3rd street
hallock, minnesota 56728

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*Name:

Middle:

*Last:

*Account #:

Business Name:

*Service Address:

*City:

*State:

*Zip:

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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