¢SiBle Checks Order Form

	New Order
	Reorder
Customer Name:
Account Number:
	If you would like your phone number printed on your checks, please list that below:
Phone Number:
Check Style:	Burgundy Marble Blue Marble Tan Parchment Burgundy Fineline Green Fineline Blue Safety Red Granite American Patriotic Daisies Wildlife (4 rotating designs: Bear, Deer, Eagle, Wolf) Desk Set: Green Parchment Desk Set: Tan Parchment Desk Set: Yellow Safety Blue Laser 3 to Page Tan Parchment
Check Type:	150 Wallets - 1 Box 150 Duplicates - 1 Box
# of Boxes:	1 2 3 4 5 6 7 8 9 10
Start Number:

If you have Netscape Navigator 4+ or Microsoft Internet Explorer 5+, the "Print Form" button will work. Otherwise put your cursor in this frame and use the browser's print function.

Your check order will be ready for pick-up at the bank two business days from the day we receive your order form. Your completed order form can be either mailed, faxed, or dropped off to Citizens State Bank at your convenience!

Mail Form To: Citizens State Bank 817 Main Street PO Box 9 Boyden, IA 51234 Fax Form To: 712-725-2571 Attention: ¢SiBle Checks Order	Thank you for your interest in