Wine Club Member Information

This is a Gift Membership     

Member Name
Shipping Address
City	State    Zip
Day Time Phone
Email Address
Date of Birth	(Must be at least 21 years or Older).
	Please fill in ALL club information or your membership will not be valid.

Payment Information

Card Holder's Name	(If different from club member information)
Billing Address
City	State     Zip
Payment Method	VisaMastercardAmerican ExpressDiscover
Credit Card Number	Expires On
Day Time Phone
Tour The Wine Counrtry in	1 Year, Shipment Every Month2 Year, Shipment Every 2 Months3 Year, Shipment Quarterly
I Accept	By checking this box, I authorize TemeculaWinesOnline.com to bill my credit card for shipment fees, including applicable tax and shipping costs. I understand that it is my responsibility to notify TemeculaWinesOnline.com in writing if I should decide to cancel my membership after receiving two shipments. I further understand that it is my responsibility to notify TemeculaWinesOnline.com of any changes in address and/or credit card information prior to each shipment in order to avoid shipment delays and/or additional shipping costs. In signing this electronic membership form, you represent to TemeculaWinesOnline.com that you are at least 21 years of age and that the person receiving each shipment is also at least 21 years of age. Adult signature is required at the time of delivery. Alternate Application Method: If you are not comfortable applying for club membership over the internet, fill out completely, print out this form, sign, date and fax to 1-888-460-9463. Club membership faxes are securly recieved and processed by our customer service employees only. All information is handled and stored with strict confidentiality and care. Signiture:                                                                                         Date:___________________________(Signiture required for fax version only.)