Write Us Your VirtualCheck.

 

To complete your Order, please fill in this short VirtualCheck Form. A VirtualCheck is an OnLine Check. Using your existing Checking Account, you provide your Account Info, and authorize us to create a check for the Order Total. You should write out the original and keep it as a record of the transaction. We will mail you a Confirmation Voucher & you'll receive the VirtualCheck original with your statement.
Checking Account Info:

If this is your first OnLine Check Order to us, please write us your VirtualCheck for the Order Total.
We Accept

VirtualChecks
Payor Information


 Bank Transit Code
{Example: 63-751/847}


Pay To The
Order of : Herbal Doctor Remedies
Payable in US Funds
Bank Information



 Name of Person Authorizing Transaction
Bank Routing Number
 Checking Account Number

OnLine VirtualCheck "Signature"

I authorize you to use the above information to generate a VirtualCheck for the Order Total. This authorization is for this transaction only. We understand you will mail a duplicate receipt of the VirtualCheck.

E-Mail Address:
Formula Name & Number:

Quantity:
Shippimg Method:
First Class Mail: Express Mail: