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CONTACT NAME COMPANY NAME STREET ADDRESS (NO PO BOX NUMBER) CITY PROVINCE PHONE POSTAL CODE FAX EMAIL SPECIAL INSTRUCTIONS Order Information NO. OF CHEQUE QUANTITY PRODUCT NO. OF LANGUAGE STYLE NO. PARTS Eng/Fre/Bil SIGNATURE LINES COLOUR LOGO TYPESTYLE STARTING Yes/No NO. NUMBER Imprint Information Personalization to appear on cheques. Use imprint information shown on sample cheque or form. 1. 2. 3. 4. 5. Payment Method DEBIT MY ACCOUNT (attach a VOID cheque) Credit Card Number: VIS.

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