Online Check Order Form

For Bank Accounts in the Unites States Only
After filling out ALL fields below, press the Submit button to order


(Note: all fields on this form must be filled in to process your order) 
Business Name:
First Name...:
Last Name....: 
Address......: 
City.........:
State........:
ZIP Code.....:
Phone number.: (Please include area code) 
EMail address: 
  Quantity Price
YOUR PRODUCT $
  Shipping & Handling $
  Florida Residents add Sales Tax (7%) $
  Total Cost………………………………… $

(sorry this form does not add - you will have to change the figures in the editable fields before you press submit)


(enter information as it appears on one of your bank checks - USA Banks Only) 
Bank Name.:
Bank City.:
Bank State:
Bank Phone: (if known - include area code please)
Now using the following lower portion of a personal check as an example, 
enter the information that appears at the bottom of your check.
MICR line at bottom of check
Bank Routing or "Transit" Number:
Your Account Number.............:
Check Number....................:

Optional - Enter here any special comments or other information we need to know such as if your ship to address is different than what is listed above.

OK - 1 more step. To confirm your order, email address, and the correct numbers, we will ask you to enter the complete row of numbers at the bottom of your check and your Internet email address below. your entry here must be complete, and will act as your signature confirming your order and intent.

Complete row of numbers at bottom of check:

To verify your email address, enter your Internet email address again here:

By choosing "Submit" you authorize YOUR COMPANY draft your bank account for the "Total Cost" amount shown on this form in return for YOUR PRODUCT. You acknowledge that you are the owner or authorized signer on the account information entered in this form. Your order will be processed through your local bank as a normal check and your account will never be accessed electronically. After you have entered the information, there is no need to send the check to us. Simply write the ordering information in your checkbook, just as if you had sent it in.


After you press the "Submit" button and receive the "thank you" message, you may choose the back button on your web browser to return to previous web pages.