Personal Check Information Form

1) Please enclose a Voided Check, Canceled Check or the Reorder Form from your existing check supply.

2) Make all changes to your sample checks directly to the face of the check.  We will make your new checks based on that check.

3) Enclose a Deposit Slip from your existing supply. 

4) Mail these items with appropriate payment (Check, MC, Visa) to................................. R&G Banknote, P.O. Box 150, Milford, NH 03055.

Name: _______________________________________Phone:___________________________
Choose Your Check Design Personal Check Information
____Michelangelo Please start my checks with #________
____Van Gogh / Monet (If not specified, we will start your new checks with #1001)
____Body Smells Add Your Personal Message: (2 lines 40 characters per line including punctuation and spaces)
____Insect Checks ______________________________________________
____Skulls ______________________________________________
____Anatomy Checks
____E. Munch's The Scream ____200 Single Checks         @ $18.00 per box _____
____Vultures ____150 Duplicate Checks   @ $20.00 per box_____
____The Dance  ____Priority Mail Delivery (optional) @.$4.00 ________
____Reclining Nudes Total   For Personal Checks:$_________
____Variety Pack 1 (4 Designs)
____Fine Art Pack (13 Designs)

Choose Address Labels Design Address Label Information.
____Michelangelo First line up to 30 characters and spaces, 
____Gabrielle d'Estree second and third lines up to 35 characters and spaces.
____The Dance ______________________________
____E. Munch's The Scream        ________________________________________
____Insects                              ________________________________________
____Skulls
____Variety Pack (all 6 designs)                    number of books @ $8.95(shipping included) ____
Total for Address Labels $___________

Merchandise Orders
(writing pads, night lights, scratch pads, etc.)

Item # Item Name Quantity Item Price Total Price for Item
1.  ______         ____________       ______      _______           $_____________
2.  ______         ____________       ______      _______           $_____________ 
3.  ______         ____________       ______      _______           $_____________ 
4.  ______         ____________       ______      _______           $_____________ 
5.  ______         ____________       ______      _______           $_____________ 
                                                                                                    + $4.95 shipping for merchandise
Total for merchandise order. $_____________ 

mastercard___visa____

Card #  ________ ---- ________ ---- ________ --- ________
Expiration date____ / ____
Please don't forget to mail your payment.
Total Due For Order $___________

Bulk Rate shipping is included in the price of the checks. Unless otherwise specified, your order will be mailed to the address printed on your checks. Please allow 4-5 weeks for free Bulk Rate Delivery. Allow 2-3 weeks for Priority Mail Delivery.

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