TMAN Membership Payment by E-Mail Form

If you prefer to order by phone call 1-800-982-6476
or print this page and FAX it to 407-482-1896
I wish to place an order, and hereby authorize RTI Inc. to duplicate the following check information in bank draft form. I will retain my original information for my/our record of this transaction. This authorization is for this transaction only. No other bank drafts may be created without my/our direct authorization.
Mr.  Mrs.  Ms.  Miss  Dr.  
Last Name   First 
City        State   ZIP 
Phone No.    Fax No. 

Select one

Account Name Bank Name Bank Phone #: (800# on bank statement) Check Number Branch Code Line 1 (small #'s under check #) Branch Code Line 2 (small #'s under check #) Transit Number (all digits at bottom of check) Transit Number (enter above numbers again) Purchase Amount (total of items being purchased) Memo to be printed on draft check
I understand that by submitting this authorization form via electronic means that this authorization shall be considered the same as if I had signed and dated this authorization. I further understand that RTI, Inc. will charge me $25 if this check draft is returned for insufficient funds.
Include Additional Details or Comments

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This page created and maintained by Ron Valli.