TeleCheck ® Checks By Phone Service sm

Customer Data Form

Personal Information

Date:
Consumer Name or Company Name
Street
City
State
ZIP
Phone   

Checking Information

Amount
MICR Line Enter all digits from left to right with no spaces or symbols
Check Type Personal  Company
Check #
ID Type
ID Number Enter numbers and/or letters only. Do NOT enter dashes, spaces or slashes.
Unique ID #



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