CheckMAN Fax/Mail Order Form

CheckMAN™ E Z ORDER FORM

Print This Form and Mail or Fax To :

Capital Merchant Solutions, Inc: CheckMAN Division ~ 3005 Gill Street ~ Bloomington, IL 61704

Fax: 312.803.1888 (24 hours) or if busy: 309.452.7035

HOME

[X]	I would like to Order The Following

[ ]	CheckMAN Standard Edition	$45.95 ($39.95 + $6 Priority s/h)
[ ]	CheckMAN Professional Edition	$85.95 ($79.95 + $6 Priority s/h)
[ ]	CheckMAN Standard + 300 Checks	$65.95 ($39.95 + $20 + $6 Priority s/h)
[ ]	CheckMAN Professional + 300 Checks	$100.95 ($79.95 + $15 + $6 Priority s/h)
[ ]	EXPRESS Delivery CheckMAN Pro + 300 Checks	$114.95 ($79.95 + $15 + $20 EXPRESS s/h)

[ ]	Illinois Residents, please add 7.25% Sales Tax: [ ] $2.90 ($39.95 Subtotal) [ ] $4.35 ($59.95 Subtotal) [ ] $5.80 ($79.95 Subtotal) [ ] $6.88 ($94.95 Subtotal)

Please Ship to:

Address:________________________________________________________

City / State / Zip:_________________________________________________

Phone & Fax:____________________________________________________

I would like to Pay By:

[ ]Check [ ]Money Order [ ]Faxed Check [ ]Visa [ ]MasterCard [ ]AmEx [ ]Discover

Name on card:______________________________________Amount: $__________

Billing Address:________________________________________________________

Capital Merchant Solutions, Inc is the name that will show up on your credit card statement.