Become a Congregation Wine Club Member (Couple)

Member #1 Name*

First Last

Member #1 Email*

Member #1 Phone*

Member #1 Women's Tee-Shirt Sizes

Member #1 Men's Tee-Shirt Sizes

Member #1 Birthday

Member #1 - What is Your Favorite Wine?

Member #2 Name*

First Last

Member #2 Email*

Member #2 Phone*

Member #2 Women's Tee-Shirt Sizes

Member #2 Men's Tee-Shirt Sizes

Member #2 - What is Your Favorite Wine?

Member #2 Birthday

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Membership *

Price: $75.00

Membership Payment Total

$0.00

Credit Card

American Express

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MasterCard

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JCB

Card Number Expiration Date Security Code Cardholder Name

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