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Black
Wolf Vineyards Wine Order Form (Shipments
within North Carolina Only)
283 Vineyard Lane, Dobson, NC 27017
Phone: 336.374.2532
Fax: 336.374.3496
(Print and complete this form and mail with payment to the
address above, or fax your order to 336.374.3496.
To comply with North Carolina alcoholic beverage laws, your
signature is required to fill your order.)
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Wine and Vintage (or n/v)
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Price
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Quantity
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Extended Price
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Cabernet Sauvignon – 2004
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$14.00
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________
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_____________
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Pinot Noir – 2005 SOLD OUT!
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n/a
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___n/a__
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_____n/a_____
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Chambourcin – 2006
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14.00
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________
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_____________
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Cabernet
Sauvignon/Merlot 50/50 "Black Magic" - 2006
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14.00
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________
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_____________
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Sweet Wolf Red - (n/v)
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12.00
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________
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_____________
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Wolfs
Lair Red – (n/v)
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11.00
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________
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_____________
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Sweet
Dreams - (n/v)
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12.00
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________
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_____________
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Chardonnay
– 2005
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12.00
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________
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_____________
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Sauvignon Blanc – 2005
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11.00
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________
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_____________
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Seyval Blanc – 2006
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11.00
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________
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_____________
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Blue Moon White - n/v
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12.00
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________
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_____________
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| Moonlight White - n/v
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12.00
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________
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_____________
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Subtotal
Wine:
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_____________
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6.75%
North Carolina Sales Tax:
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_____________
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S+H:
($20 for 1 bottle; $40 for 2-12 bottles)
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_____________
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TOTAL
ORDER:
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_____________
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Complete
the information below (All fields are required in order to fill your
order)
Your E-mail Address:_________________________________________
Your Name:_________________________________________________
Shipping Address (No P.O. Box):_________________________________
City:_________________________
NC
ZIP:____________
Day Phone:____________________
Eve Phone:____________________
Payment: Check Enclosed_____
Call Me For Card Number_____
or Card Type:_______ Card Number:__________________________
Expiration Date:___________ Card Security
Code:___________
CERTIFICATION
- I am at least 21 years of age. I have read the terms and conditions
associated with the shipment of wine to an adult recipient in North
Carolina. I understand that an adult must be present at the destination
address in order to sign for the shipment, and neither the shipper nor
Black Wolf Vineyards are responsible for unsuccessful delivery if no
adult is present upon delivery or if I have provided an erroneous
shipping address. If I have provided a charge card number, I agree to
pay billed charges.
________________________________________
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Certification Signature of Adult Customer
Date Signed
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