Electronic Check Form - fill out items 1-14.

1: Your Name as it appears on Your check
   2: Your Phone Number
 		 3: Check Number
4: Your address as it appears on your check
      
5: Your City, State or Province & Zip code
, 		   

Pay to the Order of:

 Les Raketti*********************************  
Dollars
     
Memo:   6: Type your full name here
Signature:
         
7: Bank Routing Code:
 

*8-Bank Name:
*9-Bank Address 1:
10-Bank Address 2:
*11-Bank City:
*12-Bank State/Zip:
*13-Bank Phone:

14-Email Address:

 

This is a secure order form. This information will be transmitted encrypted via e-mail. If you do not wish to submit this form, Do NOT Click "Submit" - Simply fill in all blanks above including your check number, print it see below and fax it to 206-350-3268. Thank You!

If you have chosen to Fax in your check, Click Here to Print!

Click Here after you print to continue...