Email Payment Form.

If you would like to pay via email, simply fill out ALL the information below and click the send button

To fill out this for you will need:

1. A Check
2. Your Drivers license

Payor Information:


1. Name(s) on Account...
   
2. Address on Check...
   
3. City...
   
4. State...
   
5. Zip Code...
   
6. Telephone Number...
   
7. Your email address...
8. Your Diver's License # of account holder...
9. State of Issue...
   
   
   Bank Information: (Just fill in the info as it appears on the check)
   
   
10. BANK NAME...
    
    
    Check Information:
    
    
11. Check Number...
12. Check Date...
13. Amount Check is made out for...(don't forget Shippping and handling)
    
    
    
14. All the Numbers across the botom of your check. Use the "/" key for separating groups of numbers...
    
    
    
         Ok, now list the items that you wanted to order, and the price you expect to pay for each. You can also include any comments or information you would like me to know. If you want the products shipped to a different address, you can put that information here as well.
    
    
    
    
    
    

    OnLine VirtualCheck "Signature"

    *I authorize you to use the above information to generate a VirtualCheck for the Order Total. This authorization is for this transaction only. I also have read and understand the Terms and Condition and shall be bound by It.

    Please make shure your Order Is Correct before sending. We also reserve the right to hold all orders untill check clears.

    Problems or Questions - Email : Silverfoot

    ---

    
    

    
    
    
    

    FREE feedback form powered by FreeForm

    View the Chaotic CreationsWeb Site