d’Vine Wine Club Membership Form: Fill out and return by mail, fax or stop by the shop.

d’Vine Wine Bar & Shop 5486 Chamblee Dunwoody Rd 30338 Atlanta, GA 30338  Phone: 770.396.WINE(9463)  Fax: 770.350.9977 

 

NAME: ________________________________________Start Month: ____________________________

 

ADDRESS: _____________________________________CITY:________________________STATE:_____ZIP:____________

PHONE: _________________________EMAIL (this is our primary form of communication!):__________________________________________

Pre pay 1 year (15% discount):____   Pre Pay 6 months (10% discount):______   Monthly: ________

Monthlies will be billed automatically to your credit card the 1^st of the month. To cancel, please notify us via email 1 month prior.

CREDIT CARD INFORMATION: VISA  MASTER CARD  AMERICAN EXPRESS DISCOVER  

CARD NUMBER: ____________________________________ EXPIRATION DATE: ____________________

SIGNATURE: 

** All personal and credit card information will be kept confidential **