Join Melrose Club

Please complete the below form and either fax it to 541-673-5759 or mail it to Melrose Vineyards; 885 Melqua Road; Roseburg, Oregon 97470

We accept the following credit cards: Visa, MasterCard, Discover and American Express.

Member Information

(please complete in full)

Check One: Pick up at Vineyard Ship

Full Name:

Email:

Phone:

Street Address:

Apt/Suite:

City:

State:

Zip code:

Note:Federal law requires that wine shipments to a residence be signed for by an adult or be sent to a business address.

Gift Information

(Fill out only if sending Club Membership as a gift)

Gift Recipient:

How Long?:

Email:

Phone:

Street Address:

Apt/Suite:

City:

State:

Zip code:

Note:Federal law requires that wine shipments to a residence be signed for by an adult or be sent to a business address.

Credit Card Information

Cardholder's Name:

Card Number:

Expiration:

Date of Birth:

By agreeing to become a member of the 'Melrose Club', I am at least 21 years of age and my credit card will be billed 4 times per year just prior to receiving my seasonal bottles; each billing not to exceed $55.00 to $65.00 PLUS SHIPPING for quarterly deliveries. I can cancel my membership at any time with 30 Day Written Notice after my first 2 shipments.

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© Copyright 2006 Melrose Vineyards. All Rights Reserved.
541.672.6080; 885 Melqua Road; Roseburg, OR 97470