Pre-Payment with Interest Application

Or Fill Out Our Form Below

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 #

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.

quotecapital@gmail.com

We are Approved Insurance Provider

(916) 972-7772

Free Over-the-Phone and Online Estimates!

2021 Fulton Ave., Sacramento, CA 95825

Pre-Payment with Interest Application

Or Fill Out Our Form Below

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