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LIQUOR/WINE FORMS>
(NEW) REX GOLIATH #751325-REXNA10046 $15.00 (Receipts On 12, Write UPC's) El Paso, TX 2/28/10 Postmark 3/15/10
Purchase (12) 750 ml Bottles of Rex Goliath Wine, send in this completed form and the original
CRT with Wine purchases circled. Write UPC in space provided. 2/28/10 Postmark
3/15/10 Valid In US
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