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ACT(tm) Automated Check Transfer Authorization Form


The Alternative To Using Credit Cards


If faxing or mailing your order, please PRINT the following Authorization and Order Form or write the information asked for when you mail, email, fax or call in your order. Fill in all information completely so that we may process your order promptly. You may either FAX the information to:

Fax# (617) 539-1951

Call TOLL FREE: 1-800-595-9351

Email your order to:

SAFETY@webtv.net

Or Regular Mail to:

Prevention Foot Safety Insoles
99 Marshall Street
Winthrop, MA 02152



How many pair of Insoles you're ordering and size(s):_____________________________________________________


Routing Number: _ _ _ _ _ _ _ _ _ ( 9 digits at bottom left of the check)

Account Number__________________________

Check Number____________________________

Bank Name and Telephone #__________________________________________________

Full Name as it appears on your Checking Account_____________________________________________________

Your Street Address________________________________________________________________

Your City, State and Zip Code______________________________________________________

I Authorize John August dba Prevention Foot Safety Products to debit my account ONE time only in the Amount of __________.


After I receive the above, your order will be processed promptly. When the information is sent to the Automated Check Transfer Company, precautions are taken to insure a secure transaction.


Need more information on A.C.T.? Please visit Automated Check Transfers Website.


If you have any further questions, please send me email at: SAFETY@webtv.net


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