Husky Band Wine Club Signup Form

Membership Type:	Personal membershipGift membershipBoth
Your Information
First Name:	*
Last Name:	*
Email:	*
Billing Address:	*
City:	*
State:	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zipcode:	* (e.g. 98052)
Day Phone:	* (e.g. 9999999999)
Evening Phone:	(e.g. 9999999999)

I have a different shipping address. (No P.O. Boxes)

Shipping Address:	*
City:	*
State:	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zipcode:	* (e.g. 98052)

Payment Information
Name on the Card:	*
Credit Card Type:	Visa    Master Card    Discover    *
Credit Card Number:	*(No spaces)
Expiration Month:	--Select-- 01 02 03 04 05 06 07 08 09 10 11 12 *
Expiration Year:	--Select--20132014201520162017201820192020202120222023202420252026 *

Gift recipient's Information
Name:	*
Email:	*
Shipping Address:	*(No P.O. Boxes)
City:	*
State:	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zipcode:	* (e.g. 98052)
Day Phone:	* (e.g. 9999999999)
Evening Phone:	(e.g. 9999999999)
Number of shipments to the recipient:	1   2   3    *

I have a friend who shares my interest in fine wines and to whom I'd like you to send a Husky Band wine club brochure.

Friend's Information:
Name:
Email:
Mailing Address:
City:
State:	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:	(e.g. 98052)
	Please mention that I referred this person.

How did you hear about the Husky Band Wine Club?

* I certify that the member/recipient is at least 21 years of age and understand that an adult signature is required for receipt of all shipments.

Your Initials: *   Your Date Of Birth: *(MM/DD/YY)

You may cancel your membership in writing at anytime without furthur obligation except wines shipped prior to receipt of your notice of cancellation. Kindly email Michael Leone at mleone@washingtonwine.com if you have any questions.