Secure Wine Club Submission Form

Join Le Club and be guaranteed a bottle of each of our wines as they are released.  No contract or obligations, just complete the following form and we will bill your credit card as the shipments are mailed.  Expect about eight bottles per year.

  
     
 
Your name:  
Your email address:  
Your phone number:  
Date of Birth:  
    
Shipping Address -    
Company Name:  
Street Address 1:  
Street Address 2:  
City:  
State:  
Zip:  
     
Billing Address -

     Same as Shipping Address

  
Company Name:  
Street Address 1:  
Street Address 2:  
City:  
State:  
Zip:  
     
Credit Card Information -    
Credit Card Type:

      Visa    Mastercard

 
Credit Card Number:  
Expiration Date:  
Name on Card:  
     

 

 Checking this box attests to the purchaser's age as 21 years old or older. This also indicates that the purchaser accepts the shipping policies above and membership policies below.
     
 

 

 

  
 

I certify that I am 21 years of age or older and that the person to whom I am directing delivery is at least 21 years old. I authorize Fleur De Lys to charge my credit card for each shipment (including freight and any applicable taxes) at time of shipping. There are no substitutions allowed for the automatic wine shipment. An adult signature is required at time of delivery. Fleur De Lys will not be responsible for shipping charges incurred due to misdirected or re-shipped wines.