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Vineyards on
the Scuppernong Wine Club Membership Application Authorization to Charge Credit Card Please Print Clearly Member's Name(s):______________________________________________________ Mailing Address:________________________________________________________ City:__________________State:___________Zip:____________County___________ Email:_____________________________this will only be used to let you know of our specials and events! Home Phone: ( )____________________Work Phone: ( )_______________________ Please choose one: **Ship wine______________Pick-up at winery___________________ Please check one________Gold Membership_____________Silver Membership To be a Wine Club Member, a valid credit card must be on file. (please fill in the credit card information below) ________________________________________________________________________________________________ **Shipping address if different from mailing address:________Business or_______Residence If Business: Name of Business______________________________Attn:________________ Address (Street Address and Zip Code): _________________________________________ If Residence: Street Address:_________________________________Zip Code__________ Telephone number of shipping destination: ( )_____________________________________ ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff Type of Credit Card: VISA_______, MASTER CARD_________,DISCOVER_____________ Name on Credit Card:_________________Telephone # of card holder ( )________________ Exp. Date (MM/YY)________________Card # ___________________________________ Please choose a sweetness level you prefer: Dry___, Semi-dry____,Sweet____, or no preference___ Favorite Wine(s)____________, ______________, ____________, _____________, ___________ ************************************ I have read and agree to the terms and conditions for being a member of Vineyards on the Scuppernong Wine Club. ______________________________________________ _____________________________ Signature (I certify that I am 21 years of age or older.) Date
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