Name: Have you moved? Yes No Home Address: Home City, State, Zip Code: Home Phone Number: Cell Phone Number:

Contact Information Gift Basket Program 2016 Bacchus Wine and Beer Bistro 891 Albacore Street, Corolla, NC T: 252-453-4333 F: 252-453-2429 Bacchusobx@hotmail.com www.bacchusobx.com Name: Have you moved? Yes No Home Address: Home City, State, Zip Code: Home Phone Number: Cell Phone Number: Email: Cottage Info Cottage Name: Cottage address: Subdivision: Cottage Phone Number: Rental Company: Cottage Rental #: Access code if gated community: Payment Options Pre-pay (10% discount - Pre-pay clients will receive a monthly statement of account activity and balance). Pre-payments MUST be received by May 1st and paid by check only! Standard charges will apply to gifts delivered before receipt of your prepayment. *** If you run out of prepaid funds, shall we charge your credit card? Yes No Credit card (charged the first of the week following delivery) Visa MasterCard American Express Discover CC# Expiration Date CCV Billing Zip Code

Delivery Request 1. Who will provide a list of your renters? Homeowner Rental Company 2. As additional renters are confirmed, do you want us to add them to your delivery schedule? Yes No 3. Do you have a delivery day preference? Arrival Day No preference Other Arrival Day 4. What dates should we deliver: Start Date End Date Select all that apply: In Season Only (Memorial Day to Labor Day) All weeks with renters Specific renters only (please provide list with guests names and check in dates) Include owner weeks Include partial weeks Other 5. What do you want delivered? Gift Certificates please select denomination and delivery options ($5 delivery fee) $10.00 How many? $25.00 How many? Other: How many? Where should we take them to? When do you want them delivered? Bacchus Cakes $39.00 per delivery Triple Layer Chocolate Cake A decadent cake that can t be missed!

Stuffed Bacchus Bags: $44.00 per delivery OBX Welcome Bag - One of our most popular bags! The perfect beach welcome for the hungry traveler. Includes Bacchus Select Wine, Crackers, Olive Bruschetta, OBX Snack Mix, and gourmet chocolates. Bacchus Beach BBQ Set the stage for a fantastic BBQ experience at the beach! Your guests just need to add their favorite protein or veggies for their BBQ experience. Includes Bacchus Select Wine, BBQ Sauce, Grilling Rub, and gourmet chocolates. Soundview Sunset Bag Perfect for the first night at the beach as your guests enjoy our beautiful sunsets. The bag is designed so all products can be used separately or combined for the perfect easy first night meal. Includes Bacchus Select Wine, Outer Banks Olive Oil Company Extra Virgin Olive Oil, Pasta, Bacchus Spices, and gourmet chocolates.

Specialty Gift Baskets: $75.00 per delivery OBX Welcome Basket - Our most popular bag items packaged in a beautiful basket plus some tasty treats! Includes 2 bottles Bacchus Select Wine, Crackers, Olive Bruschetta, OBX Snack Mix, Giant Bacchus Rice Crispy treat, and gourmet chocolates. Soundview Sunset Basket Perfect for the first night at the beach as your guests enjoy our beautiful sunsets. The backet is designed so all products can be used separately or combined for the perfect easy first night meal. Includes 2 bottles Bacchus Select Wine, Outer Banks Olive Oil Company Extra Virgin Olive Oil, Pasta, Pasta Sauce, Bacchus Spices, and gourmet chocolates. Fresh Select Basket For when you really want to make an impression! Great for your returning guests and other special thank you gifts. 2 bottles Bacchus Select Wine, a selection of fresh cut specialty cheeses and cured meats, decorative cheese board, crackers, Giant Bacchus Rice Crispy treat, and gourmet chocolates. _ Design your own gift / basket Tell us what you would like and we will design a custom basket just for your guests!

**Please note: If an item is out of stock or no longer available at the same price, Bacchus Wine and Beer Bistro reserves the right to replace any item(s) with similar item(s) of the same value. 6. Personalized Card for each gift Each gift will include a small colorful card with a note specially written by you! Please tell us what your card will say. Please note that the card size is 2 x 3.5 please be brief! Same as previous message? New message? Choose the Graphic on your card: Pelican Cockle Shell Beach Chair Seagull Wild Horse Whale Beach Scene

Sandpipers Signature/Date: I agree to the terms that have been selected and approve delivery during the dates noted above. X