Rojas Wine Club Application

START SAVING TODAY!

Join the Wine club and receive 25% off your first purchase

Select One Club Level

Club Level(Required)

Level 1 - Premier

Level 2 - Exclusive

Name(Required)

First Last

Birth Date(Required)

Address

Street Address Address Line 2 City State ZIP Code

Mobile Phone #(Required)

Email Address(Required)

Card Type(Required)

Visa

Mastercard

AMEX

Credit Card #(Required)

Expiration Date(Required)

CVV2(Required)

Name as it appears on credit card

First

I prefer to pick up my order

Please ship wines to me

Signature of an adult 21 or older is required during delivery. Shipping to a business address is advised.

Shipping Information

Ship to Billing Address

Ship to Alternate Shipping Address

Name of Recipient (a business address is best)(Required)

First

Company Name

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone # of Shipping Recipient(Required)

Email Address of Shipping Recipient(Required)

If shipping to alternate, specify type of address:

Type of Shipping(Required)

Business

Residential