Virtual Check Order Form

Please enter your information below.
All fields are required to submit your Virtual Check.

Your name as it appears on your check

Your address as it appears on your check

Your city, state & zip code
,
Your phone number

Your Bank's name

Check number

           
Pay To The
Order Of:
 Heart Of Tennessee Network, LLC.
 $16.48  
   Sixteen Dollars and 48 Cents US Dollars
   Type your full name here
Memo  One month Internet Dialup access Signature 
Bank Routing Code and Bank Account Number  
    

Enter your email address so that we may send you a receipt
 

For security reasons, please enter the last four digits
of your social security number.

Please enter any additional instructions below.

 

By submitting this form you authorize us to draft your account, specified above, for the "Total" amount shown on this form in return for the products selected above. You acknowledge that you are the owner or authorized signer on the account information entered in this form. If paying by check, your order will be processed through your local bank as a normal check by the Virtual Check program, and your account will never be accessed electronically. After you have entered the information, there is no need to send the check to us. Simply write the ordering information in your checkbook, just as if you had sent it in. Please remember to remove the check from your checkbook and void the check. Keep that check for your records.