3577 Highway 158, Mocksville, NC 27028 (336) 998-3100

Welcome to the RayLen Vineyards Wine Club! Membership is free, and the benefits include:

Required Information

Name (please print clearly) ________________________________ Birth date ___________

Company (if using a business address) __________________________________________

Shipping Address (sorry, no P.O. Boxes)_________________________________________

City ____________________________________ State __________ Zip code ____________

Home Phone ___________________________ Work Phone __________________________

E-Mail _________________________________ Mobile Phone________________________

Your Preference in Wine: ___ Mixed Selection ___ Reds Only

Credit Card Information

Visa _____ MC _____ AMX _____ Discover _____

Number ___________________________________________________ Exp ______________

Billing Address (if different from above) __________________________________________

City _____________________________________ State _________ Zip code ____________

We sincerely hope that this will be the beginning of a long and happy relationship as you sample the range of fine RayLen wines sent to you! If you decide to discontinue membership at some point, you must notify us thirty days prior to the next quarterly shipment. Quarterly shipments are scheduled for January, April, July and October.

I certify that I am 21 years of age or older, and as a member of the RayLen Vineyards Wine Club I authorize RayLen Vineyards to charge my Visa/MC/AMX/Disc listed above. I also recognize my responsibility to notify RayLen Vineyards of any changes to the above information, and will not hold RayLen Vineyards responsible for errors in shipment due to incorrect of out-of-date information.

Signature _________________________________________ Date _______________

Please fax this form to RayLen Vineyards Wine Club at (336) 998-2074