C.B.S. / Copperstate Business Services, Inc.

PayBy™ Form

(Please complete both pages then fax to: (480) 614-2124 or mail to: P.O. Box 15451, Scottsdale, AZ. 85267-5451)

The PayBy™ system is an electronic system which allows you to pay for your purchases via

telephone, fax or by mail.  Whichever is more convenient for you.

C.B.S. / Copperstate Business Services, Inc. (hereinafter known as C.B.S.) has my/our authorization to print and cash my/our Personal/Business Check(s) and/or Charge the amount indicated to my/our Credit Card(s) as indicated on the form below.  I/We understand that for my/our protection, this form is a "one-time" use form and will only be used for this transaction and cannot be utilized for any future transaction(s).  Purchaser must fill out another form for future transactions.  C.B.S. "does not" sell or release personal information to any Person, Company or any other entity without the written permission of our customer's.  I/We verify that I/We am/are an authorized signer on the Checking Account(s) and/or Credit Card(s) listed on this form and hereby certify that my/our signature(s) is/are true and correct.

Customer's Name: ____________________________________________________________

Customer's Physical Address: __________________________________________________

Customer's Mailing Address: ____________________________________________________

 (If different than Physical Address)

Customer's Home Phone Number:  (________)_____________-________________________

Customer's Other Contact Number:  (________)_____________-_______________________

(i.e. Cellular, Work, etc.)

Name(s) on Check: ___________________________________________________________

(If different than Customer)

Check writer/Credit card holder's Home Address: _____________________________________

(If different than Customer)

Check writer/Credit card holder's Home Phone: (_________)_________-___________________

Bank Name: __________________________________________________________________

Bank's Address on Check: _______________________________________________________

Bank's Phone Number: (________)__________-______________________________________

Check Date: __________________________Check Number: ___________________________

Banking Institution's Number on Check: _____________________________________________

(See bottom of this page to locate this information on your check)

Bank's ABA or Routing Numbers: _________________________________________________

(See bottom of this page to locate this information on your check)

Your Checking Account Number(s): _______________________________________________

(See bottom of this page to locate this information on your check)

Amont of Check: $________________Amount Charged to Credit Card(s): $________________

Payment is for:  ________Micro 3™ ________Micro 4™  ________Micro 5™ ________Mini 3™

(Number of Systems Ordered)

Authorized Signature(s): ____________________________     ___________________________

                                                                (I/We understand that all sales are final and there are no refunds)

Printed Name(s):            ____________________________    ____________________________

Method of Shipping:        FedEx Over-Night        FedEx 2-Day Delivery         4-7 Day FedEx Ground

(Please circle desired shipping method)  (Shipping charges will be applied to all orders)

                                       

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