1. Name: 2. Address: 3. City: 4. State: 5. Zip: 6. Phone: 7. Email: 8. Card Type: (Visa, MC, Discovery) 9. Card Number: 10. Exp. Date: 11. Number of 250 ml Bottles: 12. Cost of 250 ml Bottles: ($8.00 each) 13. Number of 500 ml Bottles: 14. Cost of 500 ml Bottles: ($13.00 each) 15. Number of 750 ml Bottles: 16. Cost of 750 ml Bottles: ($17.00 each) 17. Total: (Add #12, #14, and #16)