Connoisseur Club Registration Form

Mr/Mrs/Miss/Ms     .......................................................................................................................................................

Postal Address        .....................................................................................................................................................

.....................................................................................    Postcode .....................

Delivery Address    ......................................................................................................................................................

.....................................................................................    Postcode .....................

Special Delivery Instructions    ...................................................................................................................................

........................................................................................................................................................................................

Phone (H)    ...................................................................................................................................................................

Phone (W)   ...................................................................................................................................................................

Mobile      .......................................................................................................................................................................

Email         ......................................................................................................................................................................

Payment Details

Please charge my:

    Visa   _  Mastercard  _  Bankcard _  American Express _

    _ _ _ _    _ _ _ _    _ _ _ _    _ _ _ _      

    Expiry Date _ _ /_ _

I acknowledge that membership of the Connoisseur Club requires me to purchase a six bottle

tasting case twice yearly in April and October and I authorise Blueberry Hill Vineyard to charge

this credit card account on each despatch. I understand that my credit card details will be treated

as strictly confidential at all times by Blueberry Hill Vineyard and used only in accordance with

this written authorisation. I certify that I am over 18 years of age.

Cardholder’s signature .................................................................................................................................................

Cardholder’s name .......................................................................................................................................................

Date .................................................................................................................................................................................

Date of birth ..................................................................................................................................................................

NB Please fax, mail or email to :

Blueberry Hill Vineyard

Cnr McDonalds & Coulson Roads

POKOLBIN  NSW  2320

Phone: (02) 4998 7295

Fax: (02) 4998 7296

Email: blueberryhill@hunterlink.net.au