Print out this form, complete, and fax or mail to :

Lawrence Victor Estate
P.O. Box 70,
Nangwarry, SA 5277
Phone (08) 8739 7276
Fax: (08) 8739 7344

Email: cellardoor@lawrencevictorestate.com.au           Prices are inclusive of GST and WET.

Product

Per dozen
($AUS)

Quantity (dozen)

TOTAL
2002 Cabernet Sauvignon $ 220.00    
2002 Shiraz $ 180.00    
Freight

(Additional)

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INVOICE DETAILS

Name  
Address  
  Postcode
Telephone (h) Telephone (w)
email  

[  ] VISA                            [  ] BANKCARD                            [  ] MASTERCARD 

[  ] CHEQUE (Wine dispatched on presentation)
 

Card Number

Expiry
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