Members

Please note that all fields marked with an asterisk () are required.

Member Details

Title Please choose… Mr Mrs Miss

First Name

Last Name

Email Address

Online Shop Password

Confirm Password

Address

Town/Suburb

State Please choose… Australian Capital Territory New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory

Postcode

Phone(Home)

Phone(Work)

Mobile

Fax

Date of Birth
(to comply with liquor act)

• Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /
• Month January February March April May June July August September October November December /
• Year 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915

Delivery Details

Tick here if the same as above

Address

Town/Suburb

State Please choose… Australian Capital Territory New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory

Postcode

Delivery Instructions

I wish to receive a:

Pack type

• Mixed Whites
• Reds only pack
• Whites only Pack
• Dozen selection for $222
• 6 pack selection for $117
• _{Packs are delivered in March, July and October}

Big Bully Pack each May

• 6 Bottles ($140)
• 12 Bottles ($270)

I authorise Briar Ridge to charge the credit card above for all future deliveries at time of dispatch. By becoming a member of the Briar Ridge Vintage Club I understand I will receive each year three tasting packs as indicated above. I will continue to receive these packs until I advise Briar Ridge Vineyard in writing of my decision to cancel this membership. I agree to remain a member for a minimum of 12 months. Delivery instructions are my responsibility - Briar Ridge will not be held liable for wines delivered to a previous address. I certify that I am over 18 years of age. I also understand that by providing my contact information I give Briar Ridge Vineyard permission to contact me periodically via mail, phone or email with future special offers and promotions for an indefinite period. Liquor License No. LIQW80070211

I have read and accepted the above terms and conditions