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PLC:

a004ig

Agency:

town of shelby

For:

fire department fundraising

Phone:

608-788-1032

Address:

2800 ward avenue
la crosse, wisconsin 54601

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*Last Name:

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*City:

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*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

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