Order Form

 

CHARGE TO:
NAME:
 

SITE ADDRESS (IF DIFFERENT)

PHONE (IF DIFFERENT)


ADDRESS:

ORDER NUMBER:

CONTACT NAME:

PHONE NUMBERS:
HM:  
WK:   
MOB:

JOB DETAIL:
WINDOW FRAME: WOOD/ALUMINUM?
GLASS: CLEAR/OBSCURE/COLOURED OR TINTED?

PLEASE INDICATE PREFERRED ATTENDANCE TIME.

IF INSURANCE COMPANY:

CLAIM/ POLICY/ REFERENCE:
POLICY EXCESS:
INSURED NAME:

 

EMAIL ADDRESS: AUCKLAND.GLASS@XTRA.CO.NZ