Hackersley Order Form

ORDER FORM

To order please fill out your details and decide whether you want to
print off this form and fax it to Hackersley or simply submit your
completed order online.

Please print out, sign and fax your order to Hackersley Wines on: (08) 9383 3364

Delivery costs are included for customers in the Perth Metro area.
Customers outside of this area will not be charged until contacted
and delivery details confirmed.

Name:
Address:
Post Code:
Telephone:
Email:

VARIETY

CASES

COST

Shiraz 2005
at $300.00 per case

Shiraz Cabernet 2004
at $300.00 per case

Shiraz Cabernet 2005
at $300.00 per case

Shiraz Cabernet Merlot 2006
at $300.00 per case

Cabernet 2005
at $300.00 per case

Merlot 2003
at $300.00 per case

Merlot 2004
at $300.00 per case

Sauvignon Blanc 2006
at $216.00 per case

Semillon 2005
at $264.00 per case

Semillon 2006
at $264.00 per case

Sauvignon Blanc Semillon 2007
at $216.00 per case

Verdelho 2005
at $216.00 per case

Verdelho 2007
at $216.00 per case

TOTAL

PAYMENT
				Cheque
CREDIT CARD DETAILS				Credit Card

Name on Card:
Card Number:
Expiry Date:
Signature: ________________________