DELIVERY ADDRESS: 

SURNAME:

GIVEN NAME:

STREET NUMBER:

STREET:

TOWN:

POSTCODE:

PHONE NUMBER:

FAX NUMBER:

EMAIL:

POSTAL ADDRESS:  If same as delivery address leave blank

SURNAME:

GIVEN NAME:

STREET NUMBER:

STREET:

TOWN:

POSTCODE:

PAYMENT METHOD:

Cheque: Make payable to Chocolate Hills

Card: Circle the type of card:

   Mastercard  /  Visa  /  Bankcard

Expiry Date:

Card Number:

Signature:

WINE

PRICE EACH

QUANTITY

TOTAL

Chocolate Hills 2007 Choc Cabernet Swirl

$13.00

Chocolate Hills 2006 Shiraz

$13.00

Chocolate Hills 2006 Chard/Verdelho

$13.00

NEW Chocolate Hills Traminer Reisling

$13.00

Chocolate Hills 2006 Riesling

$6.00

Chocolate Hills 2008 Verdelho

$9.00

Chocolate Hills Brut/Cuvee

$15.00

Chocolate Hills Tawny Port (1 Litre)

$15.00

FREIGHT

Please call for quote for areas outside Newcastle and Sydney area

$10.00

For Newcastle & Sydney area only

TOTAL