Form Page 2

Please complete and submit this order form via email, or print it out and fax it to us at FAX (661) 298-2080. Upon receipt of this form, we will confirm your order along with applicable state sales tax and shipping charges and notify you within 24 hours. You may also phone in your order by calling (661) 251- 4315

. The Wine Cellars of Le Chene are located at 12625 Sierra Highway, Saugus, California, 91350.

Please note: All orders will require an adult's signature at the time of delivery or receipt.

Sorry, but we can not ship to the following states: Connecticut, Florida, Kentucky, Utah and Idaho. Le Chene makes no guarantee as to your right to import wines into your home state.

Please provide the following information:

First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone
FAX
E-mail
How did you hear about us?

	BILLING
Credit card
Cardholder name
Card number
Expiration date

	SHIPPING
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Shipping Method

QTY PRODUCT DESCRIPTION INCLUDING YEAR PRICE EXT

CA State Tax is 8.25% (No tax charges on out-of-state deliveries) SubTotal

Sales Tax

Total $

QTY	PRODUCT DESCRIPTION INCLUDING YEAR	PRICE	EXT








	CA State Tax is 8.25% (No tax charges on out-of-state deliveries)	SubTotal
		Sales Tax
		Total $