La Habra, California 90631-3413

Company Name

Address

City

State

Zip Code

Phone

Fax

Email

Number of checks ordered: 250 @ $81.85 500 @$102.15 1000 @ $139.85 1500 @ $191.38 2000 @232.15

Select your color choice: Teal Marble Green Blue Mauve Gray

Company Logo on checks? Yes No

Select type of order: New Order Reorder

Select No. of signature lines; One Two .

Please include with my order:

Deposit Tickets @ $27.00 - Must have

Endorsement Stamp @ $26.00 - Must have

If Reording Checks

Account number:

Starting check no.

Authorized by: