Please fill out form completely. The following information is necessary to complete membership
Customer Name:___________________________________________
Ship to address (No PO Boxes Please)
Address
City State Zip
Credit Card Information:
Name as it appears on card:_________________________________________________
Account #_______________________________________________________________
Expiration Date:__________________________________________________________
Type of Card: VISA or MASTERCARD
I have read and agree to the terms and conditions for my order from Hanover Park Vineyard
I understand and agree that delivery time for my order is approximately 2 weeks or less after payment.
Please charge my credit card as indicated above:
Signature:____________________________________ Date:______________________
This signature certifies that I am 21 years of age or older
Please sign and fax to 336-463-2875 or send to :
Hanover Park Vineyard
1927 Courtney-Huntsville Rd
Yadkinville, NC 27055