Roadcheck Order Form

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Check #	Use Default Amount?	Dollar Amounts
1. Cover Info. Name as you would like it to appear on wallet cover.
Line 1
Line 2
2. Company Name and Address
Company Name
Address Line 1
Address Line 2
3. Amount of Checks If the default amounts are good, don't edit them. If you want to change the amounts, click no then change the amount(s) in the box(es).
Check #1	YesNo	$
Check #2	YesNo	$
Check #3	YesNo	$
Check #4	YesNo	$
Check #5	YesNo	$
Check #6	YesNo	$
Check #7	YesNo	$
Check #8	YesNo	$
Check #9	YesNo	$
Check #10	YesNo	$
Check #11	YesNo	$
Check #12	YesNo	$
4. Expiration Date of ChecksM Default expiration date will be set to December 31, 2011. If you would like it to be something else, please change it here.
Expiration Date to be used on Checks
5. Disclaimer These four lines are the default disclaimer lines. If you want them changed to something else, click No then type new disclaimer line(s) in the box(es).
Line #	Use Default Text?	Disclaimer Text
Disclaimer Line 1	YesNo
Disclaimer Line 2	YesNo
Disclaimer Line 3	YesNo
Disclaimer Line 4	YesNo
6. Quantity
50 Checkbooks at $3.50 each = $17540 Checkbooks at $4.00 each = $16030 Checkbooks at $4.50 each = $13525 Checkbooks at $5.00 each = $12520 Checkbooks at $5.00 each = $100

7. Security Type in the digits you see in the box.

1. Cover Info.