WINERY/COMPANY NAME:

PHONE NUMBER:

CONTACT NAME:

FAX NUMBER:

TITLE/POSITION:

STREET ADDRESS:

E-MAIL ADDRESS:

CITY:

STATE:

ZIP:

WEBSITE:

PURCHASE LINK:

I AM USING MY OWN U.S. IMPORTER

I DO NOT HAVE AN IMPORTER AND WILL NEED HELP WITH U.S.

NAME OF U.S IMPORTER

If you checked Box 2 above, you MUST contact our import partner,Park Street Imports LLC, at competitions@parkstreet.com. Please put COLA Waiver Request - Blue Lifestyle Competition in the subject line of the e-mail. NOTE: Blue Lifestyle IS NOT RESPONSIBLE FOR import duty fees. ALL IMPORT FEES will be BILLED BACK to the entrant.

CREDIT CARD NUMBER:

EXPIRATION:

SECURITY CODE:

NAME ON CARD: