Name:
Company:
Email:
Phone:
Fax:
Address:
City:
State/Prov:
Zip/Postal:
Country:

Lester Kelly 
4314 SouthPark
Tyler, Texas 75703
903-581-5404
kellyres@37.com

By Check or Money Order

Note: All fields must be completed. Fraudulent use of BANK information is strictly prohibited by State and Federal Laws. ALL transactions are logged and any fraudulent activity reported. If time is important to you, use your Credit Card to Order since this process is quicker.Enter all the numbers on the bottom of your check (use spaces for odd characters):
_________________________________________________ 
Name on check:__________________________________________

Address on check:________________________________________

City:____________________  State:__________  Zip:___________

Day/Night Phone #'s:___________________ /__________________

What is the FULL check number:_____________________________

Total Check Amount This Order: $____________________________

Name of Bank:____________________________________________

Bank Branch Name or Number:______________________________

City:____________________  State:__________  Zip:____________

Phone# of Bank (if not on check)_____________________________

Enter 9 digit routing #:__________________________ (see diagram)

Bank account#:_________________________ Date:____/____/____

1. All fields must be filled in. If they are not, orders may not be processed.
2. ALL BAD CHECKS WILL BE CHARGED A $25.00 FEE. NO EXCEPTIONS !

 

# Description Qty $ Each $ Totals 1. 2. 3. 4. 5. Sub-Total:  Select Shipping & Handling: $5 USA $10 Canada $24 Outside USA TOTAL ENCLOSED (including S&H) $