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Order Form
Fill in quantities required below then return to :
Clayfield Wines fax 53542679 or mail to 25 Wilde Lane Moyston VIC. 3377 or
email at : sales@clayfieldwines.com.au
Grampians Shiraz 2004 @ $ 65.00 per bottle ______________ (Maximum of 6 bottles only per customer)
Grampians Shiraz 2003 @ $ 42.00 per bottle ______________
Grampians Shiraz 2001 @ $ 65.00 per bottle ________________
Massif Shiraz 2004 @ $ 24.00 per bottle ____________
Sub-Total ______________
Add $15.00 per carton for delivery ______________
Total ______________
Method of Payment : Cheque / Credit Card
Card number ____________________ Expiry date ____________________
Phone number ____________________ Signature ____________________
Delivery address _______________________________________________________________________________
Special instructions ____________________________________________________________________
" WARNING Under the Liquor Control Reform Act 1998 it is an offence
To supply alcohol to a person under the age of 18 years (Penalty exceeds $6000)
For a person under the age of 18 years to purchase or recive liquor (Penalty exceeds $500)."
eftpos available