Vino Venerata
  Wine Club Membership Form

 Conditions of membership:
   Must be over 21
   Membership fee $10 per year
   Must enjoy wine!


 Name___________________________________________

 Address_________________________________________

 City_____________________State______Zip___________

 Email Address_______________@____________________

 Home Phone   (       )___________________   
 Mobile Phone (       )___________________
 Gender___________      
 Birth Date: Month______ Day______ Year______

 Wine club interest – check all that apply:
 ___ Wine maker  
 ___ Work in wine industry
         (If yes, what do you do?)__________________________________
 ___ Wish to assist with club functions       
 ___ Just like to drink it

 Please print this form and mail with a check or money order for $10 per membership to :
    Shelly Humula,
    1703 32nd St.
    Anacortes, WA 98221