ChecksByNet Response Personal Check

Please fill out the form below to complete your Internet test check for
Valued CrossCheck Merchant using paytoid=3702036741 as the hidden value.

	1.	Enter your first name.
	2.	Enter your last name.
	3.	Enter your street address.
	4.	Enter your city, state, and zip code.
	5.	Enter your phone number. Example: (800)555-1212
	6.	Enter your internet e-mail address to receive confirmation.
	7.	Enter the next check number in your check book.
	8.	Enter the check amount to pay Valued CrossCheck Merchant.
	9.	Enter your drivers license number and its 2-letter state code. Do not include dashes or spaces.
	10.	Enter your bank's name.
	11.	Enter your bank's city, 2-letter state code, and zip code.
	12.	Enter ALL NUMBERS from the bottom of your check starting from left to right. For each symbol encountered, enter "S" BE SURE TO INCLUDE SPACES (Estimation on the number of spaces is allowed)

Please read and approve the following authorization:	I authorize ChecksByNet to duplicate the preceding information into a bank draft form. I understand that I will receive by email, a check authorization notice, notifying me that a bank draft has been issued on my behalf for said purchase. I will retain my original check for my record of the transaction.
	I understand that the Payee or authorized agent of Payee, will sign the bank draft as my agent for this transaction only. This authorization is valid for this transaction only. No other bank drafts will be created without my direct written or verbal authorization. All returned checks are subject to a fee of $22.50 or the maximum allowed by law plus returned bank debit fee.