Remittance Form

What is your three letter Organization Code?*
(Refer to your statement for the Code.)
Make Check Payable to:*
Please type the name of your Organization exactly as it should appear on your check so your treasurer will be able to deposit it.
Please indicate if check will be mailed to a home or your organization's office:*
- Home
- Office
Enter the Company and/or Person's Name and Mailing Address for where the check should be mailed.
(Alert the company/person you designate that a check is coming and must be deposited promptly.)
Name:*
To the Attention of:
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number (required by our bank)*
IMPORTANT CHECK TERMS:
2-4 weeks after submitting this form, you will receive an email notification that the check was mailed.
A $25 processing fee will be charged to replace a lost or expired check.
If the check does not arrive within 2 weeks of the mailing notification, you must immediately notify support@orthoney.com to avoid the $25 replacement fee.
Checks expire 90 days after date of issue.
It is your responsibility to enter a complete and accurate mailing address on this form.
Under no circumstances will ORT replace a check that has been deposited.
Submitted by Name*
Submitted by Email*

By submitting this form, you accept the Check Terms shown above.
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