New Registration? (or update) *

New Registration

Update to Existing Registration

Name *

First Name

Last Name

Date of Birth *

As required for alcoholic beverage purchase

MM

DD

YYYY

Spouse or Partner's Name

If Applicable

First Name

Last Name

Club Level Requested *

Club Level Requested

Level 1 (Oregon residents, 3 bottles quarterly)

Level 2 (Oregon residents, 6 bottles quarterly)

Level 3 (Oregon residents, 9 bottles quarterly)

Level 4 (Oregon residents, 12 bottles quarterly)

Out-of OR Level 1-OS (6 bottles, 2X/Year)

Out-of OR Level 2-OS (12 bottles, 1X/Year)

Out-of OR Level 3-OS (12 bottles, 2X/Year)

OK to Email (Opt-in) *

Yes

No

Mobile Phone *

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OK to Text about Peter William business? (OPT-IN) *

Yes

No

OK to Text about other business (OPT-IN) *

For Example, Educational Wine Seminars

Yes

No

Delivery/Shipping Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing/Credit Card Address

If different from delivery address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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