Online Check-by-Email Payment Form
For USA Bank Accounts Only.
Personal Information:
(Enter EXACTLY as it appears on your check)
Full Name:
Company Name:
E-Mail Address:
City, State, Zip:
Phone Number (Include Area Code):
Bank Information:
(Enter EXACTLY as it appears on yourcheck)
Bank Name:
City, State, Zip:
Bank Phone (If on Checks ):
Check Information:
Use the Diagrams to
Identify the Information on Your Check:
Select Your Check Type: Personal Check
Business Check
Account Holder's Name:
(as it appears on the Check)
Check Date: (dd/mm/yy)
Check Number:
Check Amount:
Fraction Code (left or top)

*example: 12-3456
Fraction Code (right or bottom)

*example: 7890
Routing Number:
Bank Account Number:
Please Read the Following MANDATORY AUTHORIZATION:
By submitting this form I certify that I have read and understood the contents of this authorization.
I certify that all of the information submitted by me in the form below is accurate and current; that there are sufficient funds to cover the stated amount; that I have the authority to write checks and tender payment from said account; and that I intend it to have the same force and effect as if I personally tendered my check to
I intend to and do authorize to duplicate my check into bank draft form from the information I submit.
I understand that I will receive by email, a Check Authorization Notice, notifying me that a duplicate has been issued on my behalf for said purchase. I understand and agree that the Payee or his authorized agent, will sign the bank draft as my agent, or state on the draft "This draft is authorized by your depositor NO SIGNATURE REQUIRED" for this transaction only. No other bank drafts may be created without my prior direct written or verbal authorization.
Account Authorization:
To Authorize Please Type "I Agree" Here: REQUIRED
Please Double Check ALL Information before you submit
Please Press "Submit Order and Authorization" Only ONCE.
You are on a SECURE SERVER which may take a few seconds.

After you SUBMIT your payment, you will receive confirmation by EMAIL.
©2018 R. Smith Engineering Company