Order Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Select your Wine Visages de Loire 'Les Arpents' '23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Charles Frey, Reisling 'Messe du Matin" '22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Charles Frey, Orange 'Maceration' '22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Domaine la Paleine 'Saumur' Brut Rosé, NV 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Domaine de Leyre-Loup 'Fleurie' '22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Sandrine Henriot 'Les Charmes' '20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 I confirm that I am 21 years of age or older (Adult signature required upon delivery) * I confirm Thank you for your order.