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PLC:

a0057n

Agency:

lake country fire and rescue

For:

occupancy fire inspection fee

Phone:

262-303-4524

Address:

115 main street
delafield, wisconsin 53018

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Please check all that apply:

Business Owner

Property Owner

*Business Name:

*Cell/Contact Number:

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

*Email Address:

*Invoice #:

Please contact us with any fire inspection related questions by emailing: twasielewski@lakecountryfire.com

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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