NAME:
ADDRESS:
CITY:
STATE:
ZIP:
HOME PHONE:
CELL:
BUS:
E-MAIL:
CHOICE OF COUNTRY OF ORIGIN:
RED WINE CHOICES:
WHITE WINE CHOICES:
TYPE OF BARREL CHOICE:
FOR OFFICE USE ONLY

ABC LICENSE FEE ($25.00 FOR UP TO 4 BARRELS)                                         $___________

TYPE OF WINE OR BLEND  (__________________________)                          $___________

PAYMENT METHOD                                                                        SUB TOTAL  $___________

CASH _____  CHECK _____ CREDIT CARD_____                   LESS DEPOSIT   $___________

CREDIT CARD # ____________________ EXP _____             BALANCE DUE   $___________

NAME ON CARD _____________________________


SIGNATURE: ________________________________  DATE: __________________