PMi-- Pay with Electronic Check

	Pay On-Line Options Pay with Electronic Check

If Company Check:
Company Name:
If Individual Check:
Last Name:
First Name:

Address1:
Address2:
City:
State:
Zip:
Day Time Phone:
Email:
(Let us know what you want this electronic check to pay for; please provide as much information as you know, such as job number, etc.)

Amount:

Bank Name:
Account Type:
Routing Number:
Account Number:
Check Number:

	(note: if you receive an error after submitting, please contact your CSR; do not resubmit form, or you may duplicate your payment)

Updated October 5, 2006 10:10 AM