DINNER AND WINE TO-GO
November 21, 2020

ORDER FORM

Name

First Name

Last Name

Phone

(###)

###

####

Number of Adult Meals

Select one.

2 - $50

4 - $100

6 - $150

Number of Children Meals

$20 per child.

Meal Option 1 - Chicken

Chicken served with one side and baked potato.

Meal Option 2 - Prime Rib

Prime rib served with one side and baked potato.

Wine Option 1 - Pinot Grigio - $25

Wine Option 2 - Viognier $25

Wine Option 3 - Syrah $30

Wine Option 4 - Cabernet Sauvignon $30

Name on Credit Card

Credit Card Number

Expiration Date (Month/Year)

CVC (3-digit code)

Zip Code

I authorize Balestrieri Family Farm to charge the card provided. This charge will be processed within 48 hours and a receipt will be emailed.

I agree.