Jim Hiller's Wine Club Memberships

Your Information
First Name:	Middle Initial:	Last Name:
Address:	City:	State:
Zip Code:	Telephone with area code:	Mobile Phone:
Email Address:

Wine Selection
I would like (check one): a full case (2 bottles each of six selections) every three months a half case (1 bottle each of six selections) every three months
I'd like a full case of (check one): 0 reds & 12 whites 2 reds & 10 whites 4 reds & 8 whites 6 reds & 6 whites 8 reds & 4 whites 10 reds & 2 whites 12 reds & 0 whites 1 each of all 12	OR I'd like a half case of: 0 reds & 6 whites 1 reds & 5 whites 2 reds & 4 whites 3 reds & 3 whites 4 reds & 2 whites 5 reds & 1 whites 6 reds & 0 whites

Membership Information
I would like to join:	Half Case price	Full Case price
The Taster's Table	$60/quarter	$120/quarter
The Collector's Club	$120/quarter	$240/quarter

Gift - If this Membership is a gift, to whom should the gift notification be sent?
First Name:	Last Name:	Email Address:
Address:	City:	State:
Zip Code:	Telephone with area code:

For gift memberships please select duration
Gift Membership Duration:      1 quarter 2 quarters 3 quarters 4 quarters