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PLC:

a003bs

Agency:

village of bloomdale

For:

electric payments

Phone:

419-454-2941

Address:

206 vine street, p o box 186
bloomdale, ohio 44817

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*Name:

Middle:

*Last:

*Service Address:

*Account # ( Please enter zero's if you do not have your account #.):

Email Address:

Phone Number:

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

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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