Name On Account: ____________________ {John or Jane Doe}
Address: ____________________________ {1234 Your Street}
C,S & Zip: __________________________ {Tulsa, OK 74136}
Phone #: _______-_______-____________ {918-777-1234}

Check Number: _________________ {12345}
Branch Number: ___-______/______ {86-8631/3039}

Pay To The Order Of _www.BusinessOfficeServiceS.com_  $ ________._____
___________________________________________ Dollars
                        { Fifty Five & 00/100 Dollars }

Name Of  Bank: ____________________ {Bank of Oklahoma}
Address: ____________________________ {1234 Bank Street}
C,S & Zip: __________________________ {Tulsa, OK 74119}
Phone #: _______-_______-____________ {918-555-1234}

Numbers At The Bottom of the Check
        Bank Routing Number                  Bank Account Number
| : __ __ __ __ __ __ __ __ __ | :         __ __ __ __ __ __ __ __ __ __ __ __ __ | |
  | : 123456789 | : 9 numbers

Authorized by: ______________________   Date Authorized: _________
          {Account Holder that is Authorizing}

If you are faxing this form. You need to fax a copy of a voided check from the account you are using.