Order Form

Delivery address

Last name: .......................................................................................................................

First name: ...................................................................................................................

Address : ..................................................................................................................

               ..................................................................................................................

               ..................................................................................................................

Zip code: ............................. City: ....................................................................

tel: ..............................................................................................................

To send to:

PANTAROTTO Alfred et Maïté
Vignerons
1 robert
33890 Juillac

Tel: +33 (0)5 57 40 53 50
Fax: +33 (0)5 57 40 53 71

Check must be included with order form.