BILL TO

Your Name _________________________________________________
Your Address ________________________________________________
City _______________________ State ______________ Zip _______
Daytime Phone _______________________________________________
E-Mail (optional) ______l____________________________________

SHIP TO (if different from above)
Name _____________________________________________________
Address ___________________________________________________
City _________________________ State ______________ Zip _______

METHOD OF PAYMENT
Name of Card _______________________________________________
Credit Card Number
Expiration Date _____/_____ 3 digit code on back of card ____________
Visa _____ Mastercard _____ Discover _____ American Express _____
Check, money order, above credit cards also accepted.
Please make checks payable to Panacea Wines and
Fax to: (619) 437-1175