Member Name
Ship To (if different)
Address
Shipping Address (if different)
City
City
State
Zip
State
Zip
Phone
Email
Phone
Special Instructions
What flavors do you prefer in your
wine? Hold Ctrl key down to select
all that apply.
What is your wine preference?
Hold Ctrl key down to select all
that apply.
Acid
Floral
Wood/Oak
Dry
Sweet
Jammy
Nutty
Cream/Butter
Spiced
Pepper
Musty/Dusty
Red
White
Domestic
Sparkling
Import
Other
What style of WHITE do you
enjoy? Hold Ctrl key down to
select all that apply.
What style of RED do you enjoy?
Hold Ctrl key down to select all
that apply.
Barbera
Blend
Charbono
Chianti
Claret
Merlot
Meritage
Petite Sirah
Pinot Noir
Sangiovese
Syrah
Tempranillo
Zinfandel
Blend
Chardonnay
Chenin Blanc
Fume Blanc
Gewurztraminer
Pinot Grigio/Gris
Riesling
Sauvignon Blanc
Semillon
Viognier
Other
Other
Are you interested in Desert
wine? Hold Ctrl key down to
select all that apply.
Average price per bottle, pre-tax?
30
40
50
Any, just good!
Botrytis
Late Harvest
Muscat
Port
Sherry
Tawny
Trokenbeerenauslese
How many per month?
2
4
6
8
10
12
Other - at least 2
Other