Payer's Information

First Name:

MI.

Last Name:

Business Name (leave blank if personal):

Accept Checks by the Internet, Fax or Phone!

Business or Home Address (Street):

(Suite, Room or Apartment #):

(PO Box #):

(City):

(State)

(Zip Code):

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IN IL KS KY LA MA MD ME MI MN MO MS MT NB NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

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Phone Number (include Area Code):

Fax Number (include Area Code):

E-mail Address:

Check Information

Bank Name:

Bank City:

Bank State:

ABA Number:

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IN IL KS KY LA MA MD ME MI MN MO MS MT NB NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Bank's routing or transit number:

Checking account number:

Check Number:

Date of Check (mm/dd/yy):

Driver's License:

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E-Mail within 24-48 hours by selecting Online Pickup.
Allow up to 14 days for disk shipping.

Amount authorized (select one):

$29.95 - Online Pickup   $32.90 - Disk Shipped  $35.00 - Disk Shipped in Ohio