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Virtual Check Order Form

Returned checks and charge backs are subject to collection and a $45.00 fee.

Your Name: Your e-mail address:

 

Payor Information 


Bank Transit Code  
{Example: 63-751/847}  


 
Pay To The  
Order of : C3NTRIS INDOSENTRIS. . . .		 $  
Payable in US Funds
We require a minimum of 3 months payment in
advance for virtual check plus setup fee.
Click here for pricing help. 
 
Bank Information 



Name of Person Authorizing Transaction
 
Bank Routing Number 
Checking Account Number 
For:
 
    OnLine Check Draft Authorization
    I authorize C3NTRIS INDOSENTRIS to use the above information to generate a VirtualCheck for the Order Total. This authorization is for this transaction only.
    Comments: