General : Billing : West Central District Health Department

Name:

First Name *

Middle

Last Name *

Address:

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Email:

Phone Number:

ext Extension

Payment Amount

Purpose of Payment:

Please be specific (e.g. month, class, program, misc.)

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Cardholder Name

Credit Card #

Expiration Date

Security Code

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

General