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PLC:

a0079b

Agency:

village of merrillan

For:

campground/shelter rentals

Phone:

715-333-2332

Address:

101 s main st
merrillan, wisconsin 54754

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Site Number:

Phone Number:

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

*Email:

*Vehicle Plate / State:

*Check-In & Check-Out Dates (MM/DD - MM/DD):

*I Acknowledge- By completing this registration you agree to all campground rules and Village ordinances:

Yes

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: