ACCEPT A CHECK
Customer Payment Information Form
$5.00 administrative fee required when using this service.

Fill in the form completely to pay for services.

Year:

Make:

Model:

Vin #:

Plate #:

# of vehicles:

 

Date:

Amount of purchase:

Customer Phone Number:

DL # or Social Security #:

Authorization # (if applicable):

Customer Name as it appears on check:

Street Address:

City:

State:

Zip:

Check #:

Please fill in all numbers across bottom of check:

Bank Name:

City:

State:

Zip:

 

Comments to seller:

 

Office: (760) 241-1190  

Espanol: (760) 241-2266