Contact: Sam Fyfe Email: samjanefyfe@hotmail.com Phone: 0411 253 701 Quantity TOTAL $
bot $ doz bot $ doz bot $ doz bot $ doz bot $ doz bot $ doz six $ doz $ bot $ doz
Please accept this form as confirmation of my order in the Alice In Wondervan Fundraising Wine Drive. I acknowledge that I am over 18 years of age, and that this order will be made with cleanskins.com (Victorian Liquor License #36116320). Name: _____________________________________________ Phone: ___________________________
Suburb: ___________________________
(Please note: Address is for billing confirmation only. Wine will be delivered to fundraiser for distribution. Phone number and email address are required for contact regarding any credit card / cheque payment issues.)
Credit Card
Cash
I authorise cleanskins.com to charge the above amount to my credit card. Signature: ___________________________________________
Date: _______________
Trading as Wine AS AP Pty Ltd | Alphington VIC 3078 | Phone: 03 9024 1964 | ABN: 900 749 479 89 | Limited Liquor Licence No. 3611 6320
Trading as Wine AS AP Pty Ltd | Alphington VIC 3078 | Phone: 03 9024 1964 | ABN: 900 749 479 89 | Limited Liquor Licence No. 3611 6320