Wine Club Enrollment Form

Select Wine Club * BullFrogDelighted FrogTadpole

Select Your Wines * Red OnlyWhite OnlyMixed

Name: *

Phone: *

Email: *

Address: *

City: *

State: *

Zip: *

Ship To Address: (No PO Box or APO Box) *

City: *

State: *

Zip: *

Delivery * Pickup at Frog’s ToothShip (requires an adult over 21 years old for signature)

I am over 21 years of age. I agree for you to charge my credit card for wine, shipping, handling and taxes. *

Card Type: * MasterCardVISADiscoverAMEX

Cardholder Name (as shown on card): *

Card Number: *

Expiration Date (mm/yy) *

Cardholder ZIP Code: *

1 + 3 = ? Please prove that you are human by solving the equation *