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GO FOR THE GOLD TOURS and The G.G.P.A.
ENCRYPTED
E-Check Payment Form


THIS IS A TRUSTE PRIVACY WEBSITE

Fields Marked With * Are optional.

Part #A Check Number
Part #B
 Branch Number
(usually in a format similar to 50-9999/9999)
Part #C Your Name
Address:
City, State & Zip-code
(exactly as it appears on check):
Part #D Bank Name:
Address:
City, State, Zipcode
(exactly as it appears on check):
Part #E Bank Transit Number:
(Must be a 9 digit number)
Part #F Account Number:

Shipping Information

Product Costs & Shipping

Name and Mailing address
to send your order to:
Name, Address, City, State, Zipcode

Please be sure to include any Suite #, Apt.# or office # that may be needed.

Your Phone No:             (###) ### - #### 
Your Email Address: (ex: yourname@domain.com)

Quanity Ordering:
Product Cost $
Shipping-Handling $
Product Ordering
Where did you hear about us?

Ex.: Internet auction, Friend, Newsletter, Newspaper, Search Engine, Banner,etc.

Referal Code #

If you don't know this, leave it blank.

*Optional Services NOT REQUIRED

*Shipping and Handling
(Fill in Listed Amount)		 (Fill in Listed Amount) $
* Insurance (Call for Current Rate) $
ADD UP YOUR GRAND TOTAL TO DRAFT $

Electronic Signature

Please note: $25.00 service charge for all return checks. By checking
The check box below you give GO FOR THE GOLD TOURS/G.G.P.A. permission to draft this service.

(This is required or your order will not be processed)

I understand that this is a check transaction, and by clicking this box,
I'm authorizing this draft as a check, in the
amount stated above in the GRAND TOTAL BOX.

Make sure you make a note of this transaction in your checkbook. Banks will not honor mulitple checks with the same check number, so be sure to void the check you used for this transaction.

All Pages Designed & Copyright (C) 1998 Applied Computer Technology.

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