Pay by Check
Complete & submit the form below to pay your bill by check
*Denotes Required Field

*Name (Exact name that account is in):

*Address:

*City:

*State:
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
*Zip/Postal Code:

*Phone:
-
*Payment Date:

*Check Number:

*Pay To The Order Of:

*Total Amount:

*Bank Name:

*Bank Branch:

*9 Digit Bank Routing Number:

*Account Number:

*E-Mail:

Invoice Number:

Comments:


Check Acceptance Policy
By paying for your purchase with your check, you are accepting our check acceptance policy. In the unlikely event
your check is returned unpaid, you understand and agree that your check may be electronically re-deposited or if
necessary re-deposited by paper draft. You understand and agree that we may collect a return check processing
charge of $30.00 by the same means and allowable by state law. If you have any questions regarding our check
acceptance policy, please call 800-NSF-DEPOsit (673-3376). Our data processing center will be happy to answer
your questions.