Presque Isle Wine Cellars - New Registration

Customer Information (Billing Address)

(*) indicates a required field

First Name *()**	Name as it appears on Credit Card
Last Name *()**
E-Mail *()**
Street Address *()**
Street address 2
City *()**
State *()**	We can only ship to: PA, AK, FL, ID, LA, MN, MO, NE, NH, NM, NV, ND, OH, OR, VA, WV, WY, and the DISTRICT of COLUMBIA
Zip Code *()**
Phone	123-456-7890 Format

Select Wine Club Membership Option [Both Clubs may be Selected if desired] (*)

Classique Club Option 1 - One 6-bottle shipment per year

Classique Club Option 2 - Two 4-bottle shipments per year

Learn More details on the PIWC Classique Wine Club

Click Here to see the Classique Club Terms and Conditions

Creekside Club Option 1 - Two 6-bottle shipments per year

Creekside Club Option 2 - Three 4-bottle shipments per year

Learn More details on the PIWC Creekside Wine Club

Click Here to see the Creekside Club Terms and Conditions

Select ONE Option for each club you wish to join

Select Delivery Option (*)

Ship To Me Pickup at the Winery

Is this a Gift Membership? (*)

Yes No

Recipient's First Name
Recipient's Last Name
Recipient's E-Mail
Would You Like Us to Send a Gift Card?	YesNo

Different Shipping Address?(*)

YesNo
Select YES if Shipping Address different from Billing Address

	Shipping Address (only if different)
Shipping Street Address
Street address 2
City
State	We can only ship to: PA, AK, FL, ID, LA, MN, MO, NE, NH, NM, NV, ND, OH, OR, VA, WV, WY, and the DISTRICT of COLUMBIA
Zip Code

Credit Card *()**	Visa Mastercard Discover American Express Credit card will be charged at shipping
Credit Card Number *()**
Expiration(*)	Please use MM/YYYY
CVV Code(*)	3 Digit Number on Back of Card
I have read and agree to the Terms and Conditions for the Wine Club Selected(*)	I agree
	Captcha code should not be blank or invalid
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