YOUR NAME

Your Address, City, ST 00000

Date 1
________________
Pay to the order of 2 _______________________________
$ ________ 3
______________________________________________________________
Dollars 4

FIRST NATIONAL BANK

Anytown Branch

For 5 ________________
  6

⑆123456789⑆ ⑈0012345678⑈ 0001

No. 0001