Brighton Pavilion LLC

94 Cumberland St.

Memphis, TN 38112

Phone: (800)487-8033 ● Fax: (901)458-0804

Check by Fax

Fill out check as normal, and affix signed check here.

Then fill out & sign the form below.

This form must be filled out completely before faxing to our corporate office. Fax: 901-458-0804

Bank Name & Address: ___________________________________________________________

___________________________________________________________

Bank Routing Number: ___________________________________________________________

Account Number: ___________________________________________________________

Account Name & Address: ___________________________________________________________

___________________________________________________________

___________________________________________________________

Phone Number: ___________________________________________________________

PO Number: __________________ Federal ID #: _____________________________

I authorize Brighton Pavilion, LLC to convert my check and debit my account for the sale amount via draft.

Signature: __________________________________________

Do not mail check after faxing