2009-2010 ORDER FORM

Howlin' Gale Wines Pty Ltd ACN 079 009 466 ABN 33 959 859 942

Name: *

Address:*

Phone: *

email:

Special delivery instructions:

* I declare that I am over 18 years of age.

Payment Details:

Cheque made payable to

Direct Credit to National Bank - BSB: 085-921 Acct: 54-207-2834

Credit Card:

Please debit my credit card: Visa Mastercard

Name on card:

Card number:

Expiry date:

CVV: (3 digits on back of card)

Print, and post or fax your order, or PRESS -->

Wine Prices include WET tax, GST and SA Freight

DOGLAKE ROAD, LANGHORNE CREEK, SA 5255
PHONE/FAX: (08) 8537 3144