ORDER FORM

A imprim to be printed out and returned with your cheque or postal order.
Can be sent by E-mail if paying by credit card.

No order is accepted without payment.
Possibility to mix bottles in boxes of 6 or 12.

Amount :

Bottle :

Price per bottle incl.tax

Total :

Château Pineraie

1996

1995

1994

1983

TOTAL AMOUNT OF MY ORDER :

Address for bill to be sent to :

Delivery address :

Mr   Mrs    Ms
Name:
First name :
Address :

Postal code :
Town :
Tél. :
Fax :
Mr   Mrs     Ms
Name:
First name :
Address :

Postal code :
Town :
Tél. :
Fax :

Co delivery details :

Preferred delivery date :

Please inform me of the delivery of the following telephone number :

Delivery conditions :

Method of payment :

By cheque made payable to Château Pineraie.

By postal order

By credit card (with the sign CB)..................... Card number :
Expiry date :

Available soon:
Safe payment by credit card, courtesy of the Banque Populaire du Quercy et de l'Agenais.

Any comments :

Your E-mail address :

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	Amount :	Bottle :	Price per bottle incl.tax	Total :
Château Pineraie
1996
1995
1994
1983

Address for bill to be sent to :	Delivery address :
Mr Mrs Ms Name: First name : Address : Postal code : Town : Tél. : Fax :	Mr Mrs Ms Name: First name : Address : Postal code : Town : Tél. : Fax :

Co delivery details :
Preferred delivery date :
Please inform me of the delivery of the following telephone number :
Delivery conditions :

Method of payment :
By cheque made payable to Château Pineraie. By postal order
By credit card (with the sign CB).....................	Card number : Expiry date :