Wine Club Sign-Up Form

Which wine club would you like to join? *

Portalis EXPLORES (2-bottle)

Portalis FLAGSHIP (2-bottle)

Portalis FLAGSHIP (3-bottle)

Portalis FULL BOAT (4-bottle)

Portalis FULL BOAT (5-bottle)

Name of Club Member *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Is this a gift? *

Yes

No

Billing Information *

We will get your credit card info when you come in to pick up your first month's club. If this is a gift, we'll contact you directly for payment info.

Same as Wine Club Member

Different than Wine Club Member / If different, please fill out the info below:

Billing Contact

First Name

Last Name

Billing Phone

(###)

###

####

Cancellation & Shipping Policy *

I understand that I may cancel my membership at any time without further obligation, as long as Portalis Wine Shop receives notification of the intent to cancel prior to ringing up the next month's club. All club memberships must be placed and received by adults 21 years or older.

Agree

Disagree