EmailMe Form - USA Wine Members Club – Secure Membership Form

EmailMeForm

Name
First Last
Date of Birth
MM / DD / YYYY
Required to verify legal drinking age in the United States (21+).
Delivery Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Please enter the address associated with your credit card.
Cardholder Phone Number *
### - ### - ####
Used only if we need to contact you regarding your membership or payment authorisation.
Email *
Your email will be used for membership communications, shipment notifications, and receipts.

Confirm
Additional Notes
Optional: Please share any delivery notes or preferences relevant to your membership.
Payment Details
Please provide payment details below
Credit Card

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Authorization of Future Payments *
I Authorize my Future Payments
I want to use a different card for Future Payments
I authorise Ampersand Estates Pty Ltd to securely store my payment details and automatically charge my credit card $685 USD for USA Wine Members Club shipments on a quarterly basis until my membership is cancelled in accordance with the Membership Terms & Conditions.

This is a recurring subscription. Charges will continue quarterly unless cancelled.
Membership Terms & Conditions: Required* *
I confirm that I have reviewed and accept the Ampersand Estates Wine Members Club Terms & Conditions.
Cancellation Policy: Required* *
I confirm that I have reviewed and accept the Ampersand Estates Wine Members Club Terms & Conditions.
I acknowledge that once a membership shipment has been processed, cancellation does not entitle me to a refund for that shipment.
Data & Payment Security Acknowledgement: Required* *
I acknowledge that my payment details are securely stored in a PCI-compliant vault and are accessible only to authorised personnel for the purpose of processing my membership payments.
Signature
Clear

Payment Details