ORDER FORM

 

NAME : .............................................. FIRST NAME : .............................................

COMPLETE ADRESS :................................................................................................

.........................................................................................................................................

TELEPHONE : ......................................... FAX : ........................................................

E-MAIL :......................................................................................................................

........Bottle(s) Reference n° ............ to ............ € Total .......... €

........Bottle(s) Reference n° ............ to ............ € Total .......... €

........Bottle(s) Reference n° ............ to ............ € Total .......... €

........Bottle(s) Reference n° ............ to ............ € Total .......... €

........Bottle(s) Reference n° ............ to ............ € Total .......... €

.........Bottle(s) Reference n° ............ to ............ € Total .......... €

Total :............... €

Transport :............... €

Obligatory insurance : ............... €

General total : ................. €

MEANS OF DELIVERY

 

Always Prepaid

X

METHOD OF PAYMENT

By postal, bank cheque or postal (money ) order or Western Union.

ORDER FORM AND PAYMENT TO SEND TO :

DARTIAILH Jacques

177 bis, Avenue du Général Leclerc

33600 PESSAC

FRANCE