Checker Software

 
[FrontPage Save Results Component]

Order form
Order Now Pay By Online Check, Fax or Mail
Fill in your checking account information below and we will debit your account for the $

Select The Product/Service You are ordering

Name (as it appears on check): 

Street Address (as on check): 

City (as on check): 

State (as on check): 

Zip Code (as on check): 

Phone Number (as on check): (area code) 

Bank City:

Bank Name:

Bank State:

Check Number:

Routing Number (a set of 9 numbers on the bottom of your check):

Check Fraction Number exp.63-/987/543(top right of check):

Account Number:

All numbers on bottom of check

Email:

STEP #2 DELIVERY INFORMATION
If the address on the check above is different than where you want to receive your package,
please fill in the form below. If the name on the check above is from your company, please
insert your personal information below.

Name

Address

City State Zip

Area Code + Phone Number

FAX Number

Date

If ordering by mail or fax: Signature Required _______________________

Comments:

By pressing the "Submit Order " you agree to
debit your checking account for $ amount for the offer above

You May Order 3 Ways
Online - Fax - Mail

E-Mail Orders:Press the Submit Order Button after filling out form.
Mail Orders to:Elite Concepts 374 Greenwood Ave. Rumford, RI 02916
Fax Orders to: Fill in completely and print out this form and fax to: Fax# 1-401-434-7913