(SAMPLE)

Sample Order Form

By submitting this form you authorize YOUR COMPANY, at ADDRESS, to draft a check on your bank account for the amount shown below if paying by check. You will receive a copy of the check in your next monthly bank statement. If paying by credit card you agree to abide by your cardholder agreement and by pushing submit you agree to the charges you submit.
Please provide the following information for billing.
Name on Check or Card 
Company Name (If Any) 
Address  
City  State  Zip
Phone Number 
email Address 
Pay by MasterCard / VISA / American Express / Discover
Card Number  Exp. Date 
OR
 Pay By Check
Bank Name 
Bank City  Bank State 
Fraction (Example 5-215/1011) At Top Right of Check
Check Number 
Account Number
Routing Number  
Enter Total sequence at bottom of check / left to right:
 (Or use for check memo)
 
 
PRODUCT:


Option AOption BRadio Buttons
Check Boxes
Scrolling Text Box
Text Box
Mix and match the components to make the order section you desire.  List your products, prices, order numbers and more.

 

 
            Enter The TOTAL amount of your order --->  $

*By entering the amount and pressing submit you agree to allow YOUR COMPANY to draft a check for the above amount if paying by check. You also agree to the terms and conditions of your credit card agreement. All returned checks will be subject to a collection fee not to exceed $35 and will vary from state to state. Declined or disputed credit cards are subject to a $49 processing fee. By submitting this order you agree to use the payment method above to pay for the entire order.