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PLC:

a006sb

Agency:

town of pleasant springs

For:

dog license

Phone:

608-873-3063

Address:

2354 county highway n
stoughton, wisconsin 53589

*Required Field

Payment Information

Note: After March 31st, a late fee of $10.00 per tag must be paid in addition to the regular license fee.

*Name:

Middle:

*Last:

*Address:

*City:

*State:

*Zip:

*Phone Number:

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

Email:

*Dog 1:

Dog 2:

Dog 3:

Dog 4:

Notes (please explain):

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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