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

Title Please choose… Mr Mrs Miss

First Name

Last Name

Email Address

Address

Town/Suburb

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

Postcode

Special Delivery Instructions

I would like the following pack:

Pack type

• Mixed Pack
• Whites Pack
• Reds pack

Pack Options

• Eleven Wines & Two Food Products
• Twelve Wines Only

As a member of The Tallevera Grove, I understand I will receive two wine & food packs each year. I will continue to receive these packs until I advise Tallavera Grove 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 - Tallavera Grove Vineyard will not be held liable for packs delivered to an incorrect address. I certify that I am over 18 years of age. I also give permission for Tallavera Grove Vineyard and its representatives to contact me periodically via mail, phone & email, with future special offers and promotions. Liquor Licence No. 24009758

I have read and accepted the above terms and conditions