Check By Fax Form

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Check by Fax Form

Customer Name:________________________________________________

Billing Information:

Street Address:_______________________________________________

City, State, Postal/Zipcode:__________________________________

Bank Information:

Name on Checking Account:_____________________________________

Bank Name:____________________________________________________

Check Number:_________________________________________________

Dollar Amount:________________________________________________

Additional Instructions:_____________________________________

_____________________________________________________________

I hereby authorize a bank draft on the account designated above for the amount shown. I also understand that if this check/draft should be returned for insufficient funds (NSF), the amount will be electronically debited from my account, in addition to a return fee of $25.00.

Authorized Signature:_______________________________________

Print Name:_________________________________________________

Place Check in the box below.
Please Fax This Completed Form And The Check To Be Drafted On To: (561) 586-1112