Standard Form – Checks

PLEASE VIEW THE SOURCE OF THIS ORDER FORM

(Your Company Name) Order Form

Please complete the following form to place your order. We will calculate the form and confirm your order by email.

One Month Subscription
$19.95
Three Month Subscription
$35.95
Six Month Subscription
$49.95
One Year Subscription
$59.95

General Information

First Name:	Last Name:
Address:
City:	State:	Zip:
Country:
Phone Number:
E-Mail Address:

Checking Account Information

At the bottom of your check is a series of numbers, separated by symbols. It is not necessary to enter symbols or spaces in the fields provided below.

Enter the series of nine numbers
between this symbol

Enter the series of numbers
found before this symbol

Check number to use:

Note: Some banks use a non-standard format in this series of numbers. If your account number includes this symbol , simply disregard the symbols and enter this section of numbers.

Please submit this form only once. Pressing the submit button multiple times will cause duplicate orders and charges to your checking account.