Membership Information Name * First Name Last Name Member DOB * MM DD YYYY Email * Phone (###) ### #### Tier Selection * Tier One Tier Two Name on Credit Card * First Name Last Name Credit Card Number * Expiration Date * MM DD YYYY CCV * Credit Card Type * * *I hereby authorize Everly Farms Winery to charge the credit card indicated on this form according to the terms outlined herein. I acknowledge my card will be charged for agreed upon goods/services two weeks prior to the scheduled allocation pick up. Billing Information * Address, City, State, Zip Shipping Address Address, City, State, Zip Thank you! Questions? Contact Us. Thank You & Welcome to the Family!
