Check Payment by FAX Form

Steps
1. Pull out the next valid check from your CheckBook.
2. Fill out your check as you normally would.
   Make payable to WEBster Computing Services
   Write bold and clearly, sign it normally.
3. Fill out this page and tape your signed check to the top.
4. FAX IT TO: 508-987-3638 or if busy 866-779-3227 
5. Make sure to place a note in your check balancer of the amount you spent and the check number. You will see the transaction in your monthly statement soon. Keep this sheet as a receipt. This authorization allows us to accept payment ONLY for the amount specified below and for the check number selected.

   If requesting automatic monthly deductions, a random check number will be used each month. Thank you.

NAME:___________________________________________________

COMPANY:________________________________________________

ADDRESS:________________________________________________

CITY:________________ STATE: __ ZIP: ___________________

PHONE:____________________ FAX:_________________________

EMAIL:____________________ BANK PHONE:__________________

COPY THIS INFORMATION FROM YOUR CHECK FOR COMPARISON PURPOSES
from the number line at the bottom of the check:

BANK #:_________________ ACCOUNT #:_________________

from the lightly printed numbers usually at the upper-right
corner of your check, looks like a fraction: (ex: 12-3456/2340)

ROUTING NUMBER (top or left of fraction):    ____________

ROUTING NUMBER (bottom or right of fraction):____________

** I authorize payee (WEBSTER COMPUTING SERVICES) as signatory agent for 
my check #_________ for the amount of $_______________ in United States dollars.

** I _________ (write do or do not) further authorize payee
(WEBSTER COMPUTING SERVICES) to use this checking account to automatically deduct 
me for monthly services rendered.  Monthly deduction not to exceed $___________.

** SIGNATURE (sign here):________________________________

Routing Number Example: