Peter William Club Registration Form Items marked with a red asterisk (*) are required for completion of this form. Name Date Referred by Club Level Desired Please Choose Your Desired Level In-Oregon Level 1 (3 bottles Quarterly) In-Oregon Level 2 (6 bottles In- Quarterly) In-Oregon Level 3 (9 bottles Quarterly) In-Oregon Level 4 (12 Bottles Quarterly) Out-of State Level 1-OS (6 btls 2X/yr) Out-of-State Level 2-OS (12 btls 1X/yr) Out-of-State Level 3-OS (12 btls 2X/yr) Date of Birth Email Address Mobile Phone Number OK to Text (Please Select) Yes No Include me (opt-in) to recieve text & email messages regarding private educational wine tastings (not related to Peter William Vineyard) Yes No Landline Phone Delivery Street Address City State Zip Code Credit Card Billing Address (if different from delivery address) Credit Card Type Visa MasterCard Discover American Express Credit Card Number Exiration date Credit Card Security Code People Authorized to Pick Up your Wines Other Information/Notes you think we might need I have reviewed and accept the Peter William Vineyard Privacy Policy. https://peterwilliamvineyard.com/privacy-policy/ Accepted Please Check the box to Authorize Digital Signature Authorized Digital Signature Submit Registration click here for Club Terms & Conditions on our main club page click here to review the Peter William Vineyard Privacy Policies.
