Brimstone Hill Vineyard  Valentine Event Reservations Form

61 Brimstone Hill Road, Pine Bush  New York 12566            Tel:845-744-2231

Name: ______________________________________________________________________________________________________

Street ______________________________________________________________________________________________________

City, State, Zip: _______________________________________________________________________________________________

Phone (required): _______________________________________________________________________________________________

Credit Card #:____________________________________  Type:  MC  VISA  AMEX  DISCOVER      Expiration Date:______________

_{20% discount on any case purchase (case=12 bottles)    3% discount on 3 to 11 bottles of wine purchased.}

Enclose Payment:  Check payable to Brimstone Hill Vineyard or provide Credit Card Information above.                                Thank You