MAIL ORDER FORM
Off Licence (Vigneron) 24004687           Please read our Privacy Policy
PLEASE PRINT OUT THIS FORM, FILL IT IN AND FAX IT TO US
OR EMAIL YOUR ORDER WITH DETAILS BELOW TO finewines@undercliff.com.au

Wine Price Qty Amount
Special Reserve Shiraz $396.00 per case __________ $__________
1995 Shiraz $396.00 per case __________ $__________
1999 Shiraz $300.00 per case __________ $__________
2000 Shiraz $300.00 per case __________ $__________
2001 Shiraz $216.00 per case __________ $__________
2002 Shiraz $192.00 per case __________ $__________
2003 Shiraz $192.00 per case __________ $__________
2004 Shiraz $192.00 per case __________ $__________
Sparkling Shiraz $264.00 per case __________ $__________
2003 Muscat $264.00 per case __________ $__________
1999 Semillon $204.00 per case __________ $__________
2000 Semillon $204.00 per case __________ $__________
2001 Semillon $168.00 per case __________ $__________
2002 Semillon $168.00 per case __________ $__________
2003 Semillon $168.00 per case __________ $__________
2005 Semillon $168.00 per case __________ $__________
DELIVERY $12.00 TO MAJOR NSW DESTINATIONS. POA OTHER AUSTRALIAN DESTINATIONS

NAME_____________________________________________________

Date of Birth_____________________Required by NSW Liquor Act 1982

DELIVERY ADDRESS________________________________________

____________________________________________________________

TELEPHONE, WORK____________________HOME________________

FAX_____________________EMAIL____________________________

CHEQUE / MONEY ORDER ENCLOSED $_________________

BANKCARD / VISA / AMEX / MASTERCARD No.

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NAME ON CARD____________________EXPIRYDATE__________SIGNATURE____________________

THANKYOU FOR YOUR ORDER

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