Wades Wines Order Form Bill To: Ship To: [ ] Same Name: ____________________________ Name: ____________________________ Address: _________________________ Address: _________________________ City: ____________________________ City: ____________________________ State: _____ Zip Code: ___________ State: _____ Zip Code: ___________ Phone#: __________________________ E-mail: __________________________ [ ] Please check box to verify that you at least 21 years of age ========================================================================== [ ] Credit Card Type: Visa/MC/AMEX Card#: __________________________ [ ] Check Card Exp. Date: _________ [ ] Money Order Name on Card: ___________________ Credit-Card Address Zip Code: ___________ Quantity Description Price ========================================================================== ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ ________ _______________________________________________ $__________ Total # of Items Sub-Total $__________ ________ (CA residents) tax 7.25% __________ Shipping __________ Insulated Foam Shipper __________ Insurance ($0.50 per $100) __________ UPS Adult Signature Fee ($3.50 per package) __________ Total $ __________ ========================================================================== Phone: 805-522-4445 Fax: 805-522-7444 Email: sales@wadeswines.com