Payment - Glass World

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address City Province Postal Code

Glass World Quotation Number(Required)

Deposit Amount(Required)

Credit Card Type(Required)

Credit Card Number - First 12 Digits(Required)

Enter first 12 digits of credit card.

Credit Card Number - Last 4 Digits(Required)

Enter last 4 digits of credit card.

Name on Card(Required)

Expiry Date (Month)(Required)

Expiry Date (Year)(Required)

CVV Value(Required)

Enter 3 digit value on back of card.

Glass World COD Policy(Required)

By checking the box below and submitting this form you verify that you are the card holder and that you authorize Glass World to process your card for the above amount. Upon completion of the job, Glass World will automatically debit this card for the outstanding balance on the work order.

I agree