Rockbridge Vineyard Ordering Form
(US orders – selected states only - see below)

Item Price per bottle Quantity Total Cost
2003 DeChiel Chardonnay $ $
2004 Chardonnay $ $
2004 St. Mary's Blanc $ $
2004 Tuscarora White $ $
2004 Vignoles $ $
2004 Traminette $ $
2004 White Riesling $ $
2001 Chambourcin $ $
2003 Tuscarora Red $ $
2004 Rockbridge Pinot Noir $ $
2004 DeChiel Pinot Noir $ $
2003 Heritage (Cabernet blend) $ $
2002 DeChiel Merlot $ $
Lexington & Concord (non-vintage) $ $
Jeremiah's (non-vintage) $ $
2004 V d'Or Special Sale $ $
10% discount for orders of
a case or more		 $
Add 5% VA sales tax $
Add shipping $
$

Cost will be automatically computed if you have JavaScript enabled.
Shipping cost includes a $2.00 fee for signature required at time of delivery to verify age over 21.


Please enter your name, shipping address, and type of payment:


Name
Address 1
Address 2
City
State      Zip

Select payment method:     Check or money order enclosed
Visa     MasterCard     American Express
Card number:     Expiration date:    

Signature of card holder: ____________________________


To complete your order, then mail or fax the completed order form to:
   Rockbridge Vineyard
   35 Hill View Lane
   Raphine, VA 24472 		Fax: 540-377-6204
or call the winery at 1-888-511-WINE.