|
Name__________________________________ |
email_____________________________________ |
Phone__________________________________ |
Fax______________________________________ |
Billing Address
(Please Print) |
Shipping Address
(Please Print) |
Address________________________________ |
Address___________________________________ |
_______________________________ |
_________________________________ |
City____________________________________ |
City______________________________________ |
State________________________Zip________ |
State________________________Zip_________ |
Billing Phone__________________________ |
Shipping Phone__________________________ |
You
must be 21 years old to purchase wines. We can not ship to Post Office box
addresses.
Credit Card: VISA MasterCard AMEX
(Circle One) |
Card #_________________________________ |
Expiration Date_____________________________ |
Signature_______________________________ |
Date_____________________________________ |