Loyalty Club Registration

Wine Club Form

First Name *

Last Name *

Date of Birth

Cellphone Number *

Daytime Number *

Email *

Password *

Delivery Address

*Delivery Address (no postal addresses; delivery Mon - Fri 08h00 - 17h00)

Address line 1 *

Street address, company name, c/o, etc.

Address line 2

If applicable: Apartment, suite, unit, building, floor, etc

City *

Province *

Postal Code *

End Section

Acceptance

I hereby undertake to purchase 24 bottles of wine yearly

Sending