BILLING INFORMATION

First Name

First Name

Address

Date of Birth (DD/MM/YEAR)

Day Phone

Day Phone

Email

 Pickup Ship-To

SHIPPING INFORMATION (if different than Billing Information)

First Name

Last Name

Company (If applicable)

Address

WINE PREFERENCE
 White Wines Only Red Wines Only White Wines & Red Wines

ADDITIONAL DETAILS
 No wines with sugar No dessert wines No Rose No Norton

'I understand that a staff member from Rappahannock Cellars will contact me by phone at the above provided phone number within 72 hours to receive my credit card information, and I agree to be billed for two special bottles each month, at a 15% discount, until I suspend my membership.'