Copy of Order Form

Club Member Name

Birth Date (You must be 21 years of age or older to join.)

Wine Club Selections

6 Bottles, 2 Times a Year‎ 12 Bottles, 2 Times a Year‎

When do you want your first shipment?

Charge my card immediately and send my shipment right away.‎ Charge my card and send my shipment on the next distribution.‎

Company (If applicable.)

Billing Information

Phone

Credit Card Type

Name on Card

Credit Card Number

Expires (MM/YY)

Security Code

Shipping Information (If different than the billing address.)

Verification