JOIN MOOD WINE CLUB

Name *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Daytime Phone Number *

(###)

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Text Messaging *

Is it okay to text you?

Yes Please!

No thanks.

Facebook *

Do you use it?

Yes; I'm already connected to you guys.

Yes! Friend me!

No thanks.

Payment *

We do not want your credit card number to be floating out here in cyberspace. How would you like to pay for your membership this season?

Call me during the day.

Call me in the evening.

Text message me.

I would like to see you in person.

Extra Friendly Fine Print *

If I use a credit card for payment, I authorize "Mood Wine" to bill my credit card for any packages I order, and to keep my information on file should I choose to order wine. I certify that I am at least 21 years old and that if I order wine, the person receiving and signing for any shipment will also be at least 21 years old. This one-year membership is non-refundable. If I am unable to attend events, I may send someone in my place by contacting Jake or Patrick before the event. Cancellation, Hold Request, Change of Address, Change of Credit Card, must be provided in writing via email or snail mail.

Agree

Disagree