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(Your card will be charged on February, May, August, and November)

Shipping Information:
Residential	Business	Pick-up

      Please ship to the same address as above or provide the following:

Recipient(s) First & Last Name(s):____________________________________________

Street Address:__________________________________________________________

City: ____________________ State: _______ ZIP: _________ Country: _____________

Billing Information: *

Visa

MasterCard

Amex

Name as it appears on the card: _____________________________________________

Street Address: __________________________________________________________

City: ____________________ State: _______ ZIP: _________ Country: _____________

Credit Card Number: ___________________________ Exp:__________ CSV:_________

Today’s date: ______________________ Signature: _____________________________

*I agree the club will automatically charge my credit card for each shipment, including taxes, shipping and handling fees will be applied.
I agree to receive the newsletter - It is my obligation to notify the club administrator of any address changes 5 days before the club shipments are shipped - Company will not be responsible for shipping charges incurred due to misdirected shipments. I may cancel my membership in writing at any time without further obligation except for items shipped or charged to pick up at the winery prior to receipt of my notification of cancellation.
Offer only available in reciprocal states - Club member confirms they are 21 years or older - Adult signature is required at the time of delivery - Orders may be processed by an outside vender, acting as my agent, for handling.
Confidential Information: This information will not be shared or sold outside this program.