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Today's Date: Day/Month/Year

Full Name

Billing Address

City

State

Zip

Email Address

Phone

Cell Phone





Shipment Quantity (Per Shipment)
 2 3 6 12

How to Receive Wine

(NOTE: THERE MUST BE SOMEONE 21 YEARS OR OLDER TO SIGN FOR THE PACKAGE)




By checking this box, I fully understand that my wine will be automatically billed and shipped if not picked up 30 days from the emailed shipping date. I am responsible for shipping and handling




Shipping Address (if different from billing address)

City

Zip





Payment
*Note - payment will be billed to credit card prior to each shipment for wine, tax, shipping and handling.

Credit Card

Name on Card

Credit Card Number

Expiration Date





By checking this box you are verifying that you are 21 years of age or older