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PLC:

a003bm

Agency:

bruce township government

For:

property rentals

Phone:

906-748-0245

Address:

3156 east 12 mile road
dafter, michigan 49724

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Address:

*City:

*State:

*Zip:

*Email:

*Phone:

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

*Payment Type:

*Date of Rental:

(Month / Day / Year)

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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