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Lau-Nae Winery Wine of the Month Club Registration Form |
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Please print & complete the registration form. Completed forms can be faxed to (618) 282-9463 or mailed to Lau-Nae Winery, 1522 State Route 3, Red Bud, IL 62278.
Name:____________________________________________ Street:____________________________________________ City & State:_______________________________________ Zip Code:_________________________________________ Phone Number:____________________________________ Email:____________________________________________ Date of Birth:______________________________________ Credit Card No:____________________________________ Expiration Date:____________________________________
Check One (1) Category:
I wish to receive semi-sweet/sweet wines:_______________ I wish to receive semi-dry/dry wines:___________________
I understand I will pick up my two bottles of wine from the winery each month and that my credit card will automatically be charged for this wine.
_____________________________________ ___________________________ Signature Date
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Lau-Nae Winery, Inc. |