Your name as it appears on your check:
  
  Your address as it appears on your check:
  
   Your City, State & Zipcode:
  


  Bank Name:  
     
  Bank Address:  
     
   

           
  Pay To The
Order Of:
 

 Internet Billing Services
Amount:   
   
(US Dollars)   
          Memo:      
Authorized Name on Checking:        
       Routing:   Account:    Check:
 

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