Wine Club Member Signup Form

Semi Annual Whites — 15%

To sign up for the RoxyAnn Wine Club and purchase our wines you are representing to us that you are at least 21 years old. If you have questions, simply call (541) 776-2315, and press #307 to have someone personally assist you with your order.

Club Information

Level:

Semi Annual Whites — 15%

Frequency:

Semiannually

Shipping:

Is this a Gift Subscription?

We will charge your credit card prior to each shipment.

Shipments:

Enter a personal message to be included with your shipment.

Personal Information

Billing Information:

*Birth Date:

*First Name:

*Last Name:

Company:

*Address:

Please Note: We cannot ship wine to a post office box!

Address2:

*City:

*State:

*ZipCode:

*Phone:

*Email:

Shipping Address Same As Billing

Shipping Information:

*Birth Date:

*First Name:

*Last Name:

Company:

*Address:

Please Note: We cannot ship wine to a post office box!

Address2:

*City:

*State:

*ZipCode:

*Phone:

*Email:

Username/Password:

*Username:

*Password:

Must contain at least 1 uppercase letter, 1 number, and must be at least 8 characters in length.

0%Strength:

*Confirm Password:

Payment Information

*Credit Card:

*Card Number:

*Card Expiration:

*Name On Card:

Wine Club Member Signup Form

Semi Annual Whites — 15%

Member Login

Club Information

Personal Information

Billing Information:

Shipping Information:

Username/Password:

Payment Information