Electronic Check Payment Page

Part #A Check Number
Part #B
 Branch Number
(usually in a format similar to 50-9999/9999)
Part #C Your Name
Address:
City, State & Zip-code
(exactly as it appears on check):
Part #D Bank Name:
Address:
City, State, Zipcode
(exactly as it appears on check):
Part #E Bank Transit Number:
(Must be a 9 digit number)
Part #F Account Number:

SHIPPING INFORMATION

Name and Mailing address
to send your order to:
Name, Address, City, State, Zipcode

(Only if different than above)

Your Phone No:
(###) ### - ####�

Your Email Address:
(ex: [email protected])

Your Web URL

Referred by:

ITEM(s) ORDERED
QTY

��� DESCRIPTION

 PRICE

Shipping & Handling Charge:

GRAND TOTAL TO DRAFT�

Please enter any comments here or special instructions here:

ELECTRONIC SIGNATURE

I understand that this is a check transaction, and by clicking this box, I authorize Christopher Walker to draft a check in the amount stated above in the GRAND TOTAL BOX.� I further understand that I will be charged a $20 service charge for a returned check.�

(This is required or your order can't be processed)
Make sure you make a note of this transaction in your checkbook. Banks will not honor mulitple checks with the same check number, so be sure to void the check you used for this transaction.

Your host name and IP address are being captured.�
All fraudulent transactions will be investigated and prosecuted.

E-Mail: [email protected]

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