Authorization to Charge Credit Card for Hanover Park Vineyard Wine Club
Please fill out the form completely. The following information is necessary to complete your membership.
Name:_________________________________________
Email:__________________________________________
Ship to address:
(No P.O. Boxes Please)
___________________________________________
Address
___________________________________________
City 
State Zip
Credit Card Information:
Name as it appears on card:__________________________
Account #:_______________________________________
Expiration Date:___________________________________
Type of Card:
Visa
Master Card
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