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PLC:

a005qw

Agency:

city of macomb

For:

swimming lessons

Phone:

309-837-1917

Address:

232 east jackson street
macomb, illinois 61455

*Required Field

Payment Information

*Student Name:

Middle:

*Last:

*Adult Name:

Middle:

*Last:

*Sessions 1:

Sessions 2:

Sessions 3:

*Number of Sessions checked above -note $60.00 per session:

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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