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CHECKER SOFTWARE ORDER FORM
ALL fields are required.
Available in U.S. Only
.

Your Name as on Check:        

Your Address:  

City :   State / Prov:  

ZIP / Postal Code: 

Your Telephone Number with Area Code: 

Your  E-mail:

Be certain to enter a VALID email address to avoid a 5.00 shipping and handling charge.
        Default conditions will E-mail the program to you when your check clears.

Bank Name as on your check:      

Bank Branch Name or Number (If any): 

Bank City:   Bank State:

In the upper right corner there is a number                                          
   that looks like a fraction ___-___ / ____:




Type the 9 digit routing number from the bottom
(must be 9 digits):

Account Number:      

Today's Date:           Check Number:      

Amount:      

Authorization Section

I wish to place an order for Checker, I hereby authorize Stuart Kalishman to process a draft
on my bank account for the total amount listed above to pay for this purchase. I understand
I will receive a physical copy of my check in my bank statement. Please be sure to VOID the
check number you use for this purchase. This authorization is valid for this one transaction
only. No other charges may be created on your behalf without your direct authorization.

BY CLICKING THE SUBMIT BUTTON YOU HEREBY AUTHORIZE THE ABOVE CHECK NUMBER
TO BE USED AS AN ELECTRONIC CHECK IN THE AMOUNT I SELECTED.

Please allow 7 days for the bank to process your check. Once your check clears, the program
     will be either E-Mailed or Snail Mailed depending on the purchase option you selected.