MSM Shoppe.com
Electronic Check Payment by Fax
Authorization Form
Fax#: 1-603-415-9246

Please Print Legibly

Name (Last, First, Middle)
Street Address
Shipping Address
City State/Prov. Postal Code
Email Address Home Phone
(        )		 Office Phone
(        )

I authorize Scot Brown to start an electronic check payment arrangement to pay for my order. I have read and agree to the following terms:

  1. Scot Brown will process electronic checks against my bank account to pay for my orders. I will provide the check number for each purchase at the time of such purchase.
  2. I agree to maintain sufficient funds in my account to cover said electronic checks.
  3. In the event a check is returned to Scot Brown for any reason, or in the event payment is stopped on any check, Scot Brown may refuse to accept any further orders until payment on such check is received by Scot Brown. Note: a $25.00 processing fee will be charged on all returned checks.
  4. I understand and agree that this authorization will remain in affect until Scot Brown receives written notification from me stating that I am revoking the authorization.
    5.

X_____________________________________________________  Date_____________________________
Member's Signature (must match signature on file with your financial institution)

Please attach a check marked "VOID" for the bank account your are going to be using to pay for your orders. This will ensure the correct bank coding for your account. Remember to deduct the amount of each order from your account.

ATTACH VOIDED CHECK HERE
Please write the rounting number and account number
below the check in case of poor transmission of fax.
Send to Fax#: 1-603-415-9246