Online Check Payment Order Form
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Mailing Address: 
City, State, Zip: 
Item(s) Ordered / Comments: 
Payment Type  Online Check 
Online CHECK Info (USA only)  
Please use the check at the right 
to complete the information below.
*The sets of  numbers are not always in this order
Name On Check ("A" from above)
Address on Check: ("A" from  above)
City / St / Zip on Check: ("A" from  above)
Bank Name: ("B" from above)
Bank City & State: ("C" from above)
Check Number: ("D" from above)
A.B.A. Fraction: ("E" from above)
Routing Number (9 Digits): ("F" from above)
Account Number: ("G" from above)
All Numbers From 
Bottom of Check: 
(see instructions to right) 
This is Redundant, but it 
will insure accuracy.

Amount of Check:
By submitting this form, you are giving Lynn Campbell  
 permission to draft a check on your checking 
account in the amount listed directly above this box.