Club Hungerford Hill Membership Form

1. Select your membership option*:

I would like to receive the Hh New Release Mixed Dozen TWICE a year at $220 each (including freight) I would like: both red & white wines white only red only

2. Your membership details:

First Name*	Last Name*
Postal Address*
City/Town*	State*
Postcode*	Country*
Phone*	Mobile
Email Address*	Fax
Delivery Address (i.e. if different from postal address)
Delivery Instructions (ie. if not at home leave...) (transport company will not telephone before delivery)
Please enter your birthdate
Please enter promotional code (if you do not have one, leave blank)

4. Payment details:

Type* Select Visa Mastercard Bankcard American Express Diners	Number*
Expiry Date* Month Select 1 2 3 4 5 6 7 8 9 10 11 12 Year Select 2008 2009 2010 2011 2012 2013

*Denotes required field

The purpose of collecting this information is for assessing & providing Club Hungerford Hill member services & promotions. Personal information provided by you will only be used in the course of providing such mail outs & other promotional information. We acknowledge your right of access to view & update such information provided from time to time as necessary. If you do not wish to receive any further such correspondence, or your personal details changed, please contact the Club Hungerford Hill Coordinator, wines@hungerfordhill.com.au on ph. 1800 187 666. ABN: 57099064285 Liquor License: 24011966