GIFT - Peter William Club Registration Form Name of Person GIVING membership Giver's Date of Birth Name of person receiving Gift Membership Recipient Date of Birth Credit Card Type Visa MasterCard Discover American Express Credit Card Number Exiration date Credit Card Security Code Credit Card Billing StreetAddress (Person GIVING Membership) City State Zip Code Email Address of person giving Membership Mobile Phone Number,, person giving Membership OK to Text (Please Select) Yes No Date Referred by Club Level Desired for Gift Level 1 (3 bottles Quarterly) Level 2 (6 bottles Quarterly) Level 3 (9 bottles Quarterly) Level 4 (12 Bottles Quarterly) Out--of-State A (6 btls 2X/yr) Out-of-State B (12 btls 1X/yr) Out-of-State C (12 btls 2X/yr) Email Address of Gift Recipient Mobile Phone Number, recipient OK to Text (Please Select) Yes No Landline Phone Recipient Delivery Street Address City State Zip Code People Authorized to Pick Up Wines for Recipient Other Information/Notes you think we might need Please Check the box to Authorize Authorized Digital Signature Submit Registration click here for Club Terms & Conditions on our main club page
