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PLC:

a006fw

Agency:

town of waterford

For:

transfer station punch cards

Phone:

802-748-2122

Address:

532 maple street
waterford, vermont 05848

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Phone Number or Email address:

*Punch Card options:

Please enter how you want to receive the punch card in the box below. Pick up or mailing address

Notes:

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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