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PLC:

a004tx

Agency:

vermilion county animal regulation

For:

rabies tag

Phone:

217-431-2660

Address:

14775 catlin tilton road
danville, illinois 61834

*Required Field

Payment Information

Please complete each box. If not applicable, enter N/A. Select "One Time Donation" and enter $0.00 .

*Owner Name:

Middle:

*Last:

*Purchase Choice #1:

Carry the purchase choice amount down to the Pet Name Amount box.

*Pet Name 1:

*Pet Name 1 Amount:

*Vet Clinic 1:

*Date of Vaccination 1:

(Month / Day / Year)

*Breed 1:

*Date of Birth/Age 1:

*Color 1:

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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