Wine Shipping Request Form

Thank you for your interest in ordering our wines! Please fill out the form below to provide us with the necessary information for your order.

Full Name *

Email *

Please provide the best email address for order confirmation and communication

Phone *

Please provide the best phone number to reach you if needed

Address *

Street Address *

Please provide the complete shipping address where the wines will be delivered. Note we only deliver within Canada

City *

Province *

Postal Code *

Method of Payment *

Ordering as a gift?

If yes, please enter full name of recipient.

Date *

Today's date

Wines requested *

Please list the wines and quantity you would like to order and we will confirm availability. We ship in format of 3, 6 or 12 bottles

Special Requests

If you have any special requests or notes regarding your order, please specify them here.

Confirmation *

I confirm that I am of legal drinking age in my province and that the recipient may be required to show valid government-issued ID upon delivery.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Loose Wire Winery at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.