Your Name as on Check:        

Your Address:  

City :   State/Prov:   ZIP/Postal Code: 

Your Phone: 

Your  E-mail:

Be certain to enter a VALID email address to avoid a 5.00 shipping and handling charge the program will be E-mailed to you.

Bank Name as on your check:      

Bank Branch Name or Number: 

Bank City:   Bank State:

In the upper right corner there is a number
   that looks like a fraction ___-___ / ____:

Type the 9 digit routing number from the bottom
(must be 9 digits):

ACCOUNT NUMBER:      

Today's Date:           CHECK NUMBER:      

AMOUNT:      

BY CLICKING THE SUBMIT BUTTON YOU HEREBY AUTHORIZE THE ABOVE CHECK NUMBER TO BE USED AS AN ELECTRONIC CHECK IN THE AMOUNT OF $14.95.
(Please allow 7 days for the bank to process your check)