Pre-Payment Application | Capital Auto Glass Sacramento

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Fill out the form below or give us a call at (916) 972-7772. Third Party Credit Card Authorization — Please save or print to fill out if you need to authorize someone to use your credit card.

First, M, Last Name

Home Address

Phone

Text #

Email

Business Name

Contact Person

Position

Business Address

Business Phone

Text #

Business Email

Choose A Pre-Payment Plan (check one)

Platinum | 20% ($1,000–$2,000) Gold | 15% ($500–$999) Silver | 10% ($100–$499)

How Much Do You Want To Fund?

How Do You Want To Fund? (check one)

Credit Card (additional non-refundable 3% fee for credit card usage) Check — Make check payable to: Capital Auto Glass. Write “Pre-payment plan” on Memo Cash — Cash payments are accepted exclusively in store. Do not send cash via mail

Credit Card Number

Name on Credit Card

CVC Code (on back; Amex—front)

Expiration Date

Billing Address

Signature (Please Print Name)

Date

Please Initial:

By initialing here, you confirm that you have read and agree to the Terms, Rules, & Regulations of our Pre-Payment Plan.

Click Here to Download Application

We are an Approved Insurance Provider

Pre-Payment with Interest Application

Or Fill Out Our Form Below