* Name:     *    *
                                                                       ^ Numerals, no letters ^
                                                  
    *    Re-enter email:
    * PHONE
     Pay to the
     Order of                           WIDGET COMPANY.                                    * $
       _________________________________________________________________________ Dollars

    * For __ Account# or enter NEW: __          This draft pre-authorized by accountholder

          *          *
                     ^ Numerals, no letters ^                                  ^ use letter "D" in place of

ChecksNet protects your personal and bank account information from theft or misuse by encoding and scrambling the data as it is transmitted from this secure website to us. By submitting this form, you hereby authorize WIDGET COMPANY to create a bank draft for the payment above.