Name *

First Name

Last Name

Phone *

(###)

###

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I CANNOT ATTEND THE WINE CLUB PICK-UP *

Please indicate whether you'll be picking up at a later date or if you need us to ship the wine to you.

I will come to the winery during regular business hours to pick-up my wine

Please ship the wine directly to me!

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country