Club Dingo Membership Application

Name:
Residential Address:
Postcode:
Postal Address:
Postcode:
Phone (H):
Fax (H):
Phone (W):
Mobile:
Email:

I understand my membership number will be allocated by Club Dingo on receipt of my completed invitation to join. I look forward to receiving my membership certificate which will display my name and personal identification number. My member ship certificate will accompany my first delivery of wine from Club Dingo.

I authorise Club Dingo to debit my Credit card account with the appropriate amount each time a wine pack is despatched to my address. I understand my membership will be ongoing and that as a member I whill have the opportunity to enjoy additional benefits. I am over eighteen years of age.

WINE SELECTION
Please Choose your selection.
Please deliver a selection of quality wine:
Red
White
Mixed

Payment Details
Bankcard / MasterCard / Visa
(Please indicate Card Type)
CARDHOLDERS NAME:
EXPIRY DATE:
CARD NUMBER:

I authorise Dingo Creek Vineyard to bill my credit card on dispatch of the wine to me. I am over 18yrs of age.

SIGNATURE:

DELIVERY DETAILS - Please Deliver to:
Name
(Please print clearly):
Address:
Phone (work):
Phone (home):

Please mail this invitation to join Club Dingo to 265 Tandur Traveston Rd Traveston Qld 4570 or fax 07 5485 0041

On receipt of your completed invitation to join Club Dingo your membership will be processed and your individual number allocated. Your selection of Club Dingo Wines will then be forwarded to you. Cessation of your membership can only be made in writing. Your personal details will not be passed on to any other persons.