(Note: all applicable fields on this form must be filled in to process your order) 
Business Name.:
First Name....:
Last Name.....: 
Address.......: 
City..........:
State.........:
ZIP Code......:
Phone number..: (Please include area code)
E-Mail address: 

Please enter the check information below.

(enter information as it appears on one of your bank checks - USA Banks Only) 
Bank Name.:
Bank City.:
Bank State:
Bank Phone: (if known - include area code please)

Now using the following as an example, 
enter the information that appears on your check.



Bank Routing or "Transit" Number:  
Your Account Number.............:  
Check Number....................:

Enter here any special comments, AND YOUR INVOICE NUMBER WE PROVIDE.

OK - 1 more step. To confirm your order, email address, and the correct numbers, we ask you to enter the complete row of numbers at the bottom of your check and your Internet email address below. your entry here must be complete, and will act as your signature confirming your order and intent to purchase.

Complete row of numbers at bottom of check:( USE % FOR BANK SYMBOLS)

To verify your email address, enter your Internet email address again here:

By choosing "Submit" you authorize  Brush Man / Frank Szalai to draft your bank account, for the "Total Amount" amount shown on this form in return for the above order. You acknowledge that you are the owner or authorized signer on the account information entered in this form. Your order will be processed through your local bank as a normal check by  Brush Man / Frank Szalai 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 and amount in your checkbook, just as if you had sent it in. Orders are processed within 48 Hours of clearing the bank. If you have questions about your order, please e-mail , or write Brush Man, PO Box 60181 Fort Myers, FL 33906-6181. 

After you press the "Submit" button and receive the "thank you" message, you may close your browser or
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