Virtual Check FAX Order Form

Fax Form

First, fill out this form with all required information and then use your browser's print button to print it.
Then FAX the printed form to 580-357-9121. You may then use your "back" button to return to our site.

Name of Authorizing Person
Your Name / Complete Address and Additional Information as it appears on Check. 1
Daytime Phone/FAX number	P: F:
E-Mail address for Replies Please double-check!
Amount of Your Check (Numeric)
Amount of Your Check (Spelled Out)
2Check Number - Use actual check number then void the check. 3 Transit Code (ex:63-751/1002) (looks like a fraction)
Bank Name/Branch 4 Address City, State, Zip Bank Phone
Bank Area Code and Phone Number	Order will not be processed without this phone number
Routing and Account Number The check number may appear to the left or right of the actual routing/account numbers. Exclude the duplicate check number.	9 Digit Routing Number 5 Checking Account Number 6
________________________________ After Printing, please sign on the line to the left. My signature authorizes J.T. Neal Insurance Agency to use the above information to generate a VirtualCheck for the Order Total. This authorization is for this transaction only. I understand J.T. Neal Insurance Agency will send a duplicate voucher receipt of the VirtualCheck draft upon my request. We CAN NOT process your order without your signature here.