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Wine Club Application

Name*
First Name Last Name
Email*

example@example.com
Phone*
Date of Birth*
ID State*
ID Number
Billing Address*
Street Address Address Line 2 City State ZIP Code
Delivery or Customer Pickup?
- Delivery
- Customer Pickup

Delivery
Shipping Information
- Residential
- Commercial
Are the shipping and billing addresses the same?
- Yes
- No
Recipient Name
First Name Last Name
Recipient Email
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Customer Pickup
Pickup Location*
- Alamogordo
- Farm and Ranch Museum
- Mesilla
- Cork & Kettle, Ruidoso
Who will pick up your wine?*
- Myself
- Someone Else
Name
First Name Last Name
Date of Birth
ID State
ID Number

Wine Club Membership Types

Standard - 2 bottles of wine selected by Heart of the Desert, shipped every two months
Custom - 2 bottles of wine selected by Customer, shipped every two months
Wine Club Type
- Standard Wine Club
- Custom Wine Club
Custom Selection 1
Custom Selection 2
Requested Start Month
- January
- March
- May
- July
- September
- November
Comments
This field is for validation purposes and should be left unchanged.

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