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ANCHOR CLUB SIGN UP FORM '

4 Shipments per year of 3 bottles each. Average charges per shipment will range between$120-$150,

which will include sales tax and shipping.

**PLEASE PRINT CLEARLY**

BILLING INFORMATION: NAME: ADDRESS: CITY:

STATE:

ZIP CODE:

PHONE #:

(Home / Work / Cell / Other)

PHONE #:

(Home / Work / Cell / Other)

EMAIL: PICK UP AT THE WINERY? Yes / No

BIRTHDATE: _____/______/_______ (Month/

Date/

Year)

(Great option for Foxen locals to pickup within 1 month of the shipment date*)

IS THIS A GIFT? Yes / No

SHIPPING TO: Residential / Business

(If yes , # of shipments _____

(UPS requires an adult signature for delivery, we recommend

or unlimited_____)

shipping to a business address)

SHIPPING INFORMATION:  Please check here if your shipping address is the same as your billing address NAME: ADDRESS: CITY:

STATE:

PHONE #:

ZIP CODE: (Home / Work / Cell / Other)

We#ship#to#the#following#states:#AK,CA,CO,FL,GA,HI,ID,IA,IL,IN,#KS,MD,ME,MI,MN,MO,MT,NC,NE,NH,NJ,NM,NV,NY,OH, OR,SC,TN,TX,VA,WA,Washington#DC,WV,WI,#WY

PAYMENT INFORMATION: CREDIT CARD #:

EXPIRATION:

(We accept Visa, MasterCard, American Express & Discover) Terms:

    *

By#signing#this#membership#form,#I#certify#that#I#am#at#least#21#years#old I#authorize#Foxen#Vineyard#to#automatically#charge#my#credit#card#at#the#time#of#each#shipment. Foxen#Vineyard#has#the#right#to#refuse#membership#or#terminate#membership#at#any#time I#understand#that#an#adult#over#the#age#of#21#must#sign#for#shipments#at#the#time#of#delivery For#pick#up#members,#if#your#shipment#is#not#picked#up#within#1#month#of#shipment#date,#your#wine#will#be# shipped#and#the#shipping#cost#charged#to#your#card#

SIGNATURE: For Office Use Only: TR Initial: Date:

DATE: VN: LW:

7600#FOXEN#CANYON#ROAD###SANTA#MARIA,#CA##93454#####PHONE#:#805#937#4251#####FAX#:#805#937#0415