TPGS, Corp, dba The Puako General Store

69-1649 Puako Beach Drive,

Kamuela, HI 96743



Guest Name ____________________________________

Puako/Waialea Bay Address ____________________


Cell Number ____________________________________

Date of Delivery _________________________________

Food and Beverage Delivery

List items here:



I authorize The Puako General Store to deliver the listed items to the home I will be occupying. I am 21 years of age or older.


Guest signature

In accordance with state law, we are required to have proof of age on file, as well as your home address and contact phone number. Please fax proof of age along with this signed delivery form to 808-882-1395

Payment for all items must be made in the store the day after delivery


Below to be completed by store staff:

DOB on file _______Yes

Form of ID _____________________________

Date received _____________

Signed ____________________________

Owner or manager signature