Welcome to the Forth Estate!

Name of 4th Estate member/s_____________________________________________

Is it a gift membership?

If so, a gift card on your behalf will be went to the recipient.

Nope, it's for me! _____ Yes ___ (If yes, then) To: ____________________ From:_______________

Personal greeting to recipient___________________________________________________________

___________________________________________________________________________________

Name of card holder, if other than member___________________________________________

Billing address_____________________________________________________________________

___________________________________________________________________________________

Telephone #_______________________________________________________________________

E-mail address_____________________________________________________________________

Hold at winery for pick up ___ Ship to address below ____

Shipping address___________________________________________________________________

___________________________________________________________________________________

Choose business___ or residence___ shipping address

(for least expensive delivery use a business address, if possible)

Telephone # at shipping address____________________________

Credit Card#_________________________exp______________

Credit Card security code (3 or 4 digits)__________

Signature of cardholder___________________________________