Order Form

To order please fill in the following form, print it and fax it to (03) 5978 8134.
Please note the minimum order is 6 bottles. FREIGHT IS FREE!

Wine	Price	QTY	Total
Pinot Gris	$20
Chardonnay	$20
Rose	$20
Pinot Noir	$22
Reserve Pinot Noir	$45
Shiraz	$22
Total

Name:
Delivery Address:
Card Type	Visa Mastercard Bankcard
Card Number
Card Expiry	01 02 03 04 05 06 07 08 09 10 11 12 -- / 2005 2006 2007 2008 2009 2010 ----
Special Instructions
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