WINE CLUB MEMBERSHIP APPLICATION

 Shipping Information: No P.O. Boxes Please

 This is a business address     Yes      No

Will Pick up in tasting room Yes      No

Name: _________________________________________________

Address: ________________________________________________

City: ___________________________________________________

State: ______________________________ Zip: __________________

Day Phone: ______________________________________________

Evening Phone: ___________________________________________

Email: __________________________________________________

Date of Birth: ____________________________________________

Billing Information:

Credit Card Type:    Am Ex:____    MC:______       Vista:________

Credit Card# ________________________________

Card Exp. Date: ________

Name as it appears on card: _______________________

Billing Address (if different from above):_______________________

_________________________________________________________
                                         Signature

I understand that all deliveries require the signature of a sober adult.