Company Name:
Routing number from bottom of check:
Account Number from bottom of check:
Check Number:
Amount of Check:
Company Address:
Company Address 2:
City:
State:
Zip Code:
Email Address of Person Authorized to sign Company/Personal Check:
Phone Number of Person Authorized to sign Comany/Personal Check:
Name of Person Authorized to sign Comany/Personal Check:
Type of Membership with Number of Employees & Amount of check:
By supplying this information I agree that a paper draft (check) OR an Electronic Draft will be submitted to my checking account for the amount specified:
In order to pay by check (paper draft)
You must fill out the form on this page
 
 
 
YOU HAVE TWO OPTIONS:
 
 
1.  Simply fax a copy  of a check to 918-446-1103 with ALL the information included in the form on this page
 
 
 
OR
 
 
 
2.  Fill out the form on this page and submit for payment by paper draft.
 
 
 
If you have any questions you may call Jana Davis at
918-445-1115.