Name__________________________________
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email__________________________________
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Phone__________________________________
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Fax____________________________________
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Billing Address (Please Print)
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Shipping Address (Please Print)
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Address_____________________________
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Address_____________________________
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_______________________________
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_________________________________
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City___________________________________
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City___________________________________
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State________________________Zip________
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State________________________Zip________
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Billing Phone___________________________
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Shipping Phone__________________________
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You must be at least 21 years of age to purchase or receive shipment of wines. We cannot ship to Post Office box addresses.
Credit Card: VISA MasterCard (Circle One)
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Card #_________________________________
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Expiration Date_________________________
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Signature_______________________________
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Date____________________________________
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