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PLC:

a001yg

Agency:

livonia central school district

For:

registration payments

Phone:

585-346-4004

Address:

40 spring street
livonia, new york 14487

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Address:

*City:

*State:

*Zip:

*Phone #:

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

*Class/Camp registering for?:

*Date of class/camp:

(Month / Day / Year)

Notes:

Payment Amount

*Payment Type:

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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