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