Name Check No.      
     Phone       
     E-mail
     Street
     City State Zip
  Parents, Families and Friends of Lesbians and Gays, Inc. Amt $      
     Bank (MICR) Numbers*
     

 Personal
 Company
  Driver's License or State ID
  
  DL or State ID Number
     Memo/Purpose Invoice/Chapter/Order #


*Please enter all of the numbers along the bottom of your check from left to right, excluding any symbols or spaces.
For more information on the entry of the MICR number, refer to TeleCheck's Check Entry Tip Sheet.