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Secure Online Check Order Form
**All Information Listed Below Is Required For Payment Processing**
Email Address You Want Order Sent To:
Re-Enter Email Address:
First Name:
Last Name:
Check Address :
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Online Check Payment Details
Check Number:
Bank Routing Number
[nine digits-see diagram above]:
Bank Account Number[see diagram above]:
By initializing, I hereby authorize EZPick3.Com to create a bank draft in the amount of $29.95 and deposit it for this order. I also understand that in the event that this bank draft is returned unpaid, I authorize EZPick3.Com to create and deposit a second bank draft in the amount of $59.90 for the original $29.95 order amount and a $29.95 returned payment fee.
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