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PLC:

a003oy

Agency:

city of new roads

For:

market at the mill booth rental payments

Phone:

225-638-5360

Address:

211 w. main street
new roads, louisiana 70760

*Required Field

Payment Information

*Customer Name:

Middle:

*Last:

*Business Name:

*Address:

*City:

*State:

*Zip:

*Phone Number:

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

*e-mail address:

*Payment Type:

Market at the Mill

Holiday Market at the Mill

Booth Rentals - Food

Booth Rentals - Arts & Crafts

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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