Checking Form

Pay By Check

If you are human, leave this field blank.

Full Name *

First

Email *

Address *

City *

State *

Postal Code *

Phone Number *

Item(s) Ordered/Comments

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Check example

Name On Check ("A" from above) *

Address on Check ("A" from above) *

City/State/Zip on Check ("A" from above) *

Bank Name ("B" from above) *

Bank City & State ("C" from above) *

Check Number ("D" from above) *

Routing Number - 9 Digits ("F" from above) *

Account Number ("G" from above) *

All Number From Bottom of Check *

Amount of Check *