Check By Web


	Name as it Appears on Check
	Address as it Appears on Check
	Your City, State, Zip		* *
	Your E-mail Address		*
	Your Check Number		Check number can be #'s only *
	Your Bank Name		*

	Bank Routing Number		* * *
	Reenter Routing Number		* *
	Bank Account Number		**
	Reenter Account Number		* * *
	Amount of Payment