Please fill out this secure on-line form to notify us of any changes you would like to make to an existing club membership. If you prefer, you can also make changes by e-mailing us at ClubRelations@clospegase.com, or by calling 800.366-8583 ext. 201.

Step 1: Name & Member Number Please fill out this section to help us access your account.
Name: (required)
Membership Number (if known):
Phone: (required - in case we have questions!)
Email address:
Step 2: Changes to your account Please fill in only the portions that you need to be updated.
Ship to Name:	(Signature of person at least 21 years old required upon delivery.)
Business Name:	(If Applicable.)
Street:
City:
State:	Please select state Alaska Arizona California Connecticut Florida Idaho Illinois Indiana Iowa Massachusetts Michigan Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oregon Texas Virginia Washington D.C. Washington State West Virginia Wisconsin Wyoming
Zip Code:
Available states for shipping varies.
Mailing Address (for postcards, brochures, etc.):	(If same as above: )
Street:
City:
State:	Please select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Age:	Month 01 02 03 04 05 06 07 08 09 10 11 12 day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Country:	United States
Home Phone:
Work Phone:
Email:
Membership Type:	Upgrade to Monthly Shipments (Cellar Club) Adjust shipments to receive only four times a year (Pegase Circle)     Change to red and white wine selections     Change to red wine only     Change to white wine only
Additional Comments:

Step 2: Billing Information If billing information is the same as the shipping information click here , enter the name to appear on the bill and skip to step 3! Otherwise, please fill in all parts of this section.
Name:
Home Phone:
Work Phone:
Email:
Step 3: Payment Information FOR YOUR SECURITY, PLEASE PROVIDE YOUR PHONE NUMBER AND WE WILL CONTACT YOU FOR CREDIT CARD PAYMENT INFORMATION. PLEASE BE AWARE THAT IT MAY TAKE UP TO 10 BUSINESS DAYS FOR THESE CHANGES TO BE APPLIED TO YOUR ACCOUNT. Club shipments are typically charged the last week of the month prior to the shipment month. Changes must be received before the charge date to be applied to an upcoming shipment.