Private Dining Club Membership Application
2398 E. Camelback Road
Phoenix, Arizona 85016
Phone 602.957.3214
Fax 602.381.0203

Individual Name________________________________________
Company Name________________________________________

Additional Member______________________________________
 (Two (2) Individuals per account)

Home Phone Number (______ )____________________________
Home Fax Number (______ )______________________________
Work Phone Number (______ )____________________________
Work Fax Number (______ )______________________________
E-Mail Address_________________________________________

Billing Address_________________________________________
 __________________________________________
Credit Card Type: Amex ___  Visa ___  MC ___  Diners ___  Disc___
Credit Card Number _________________________Exp.__________

Signature X____________________________ Date___________

(Your signature authorizes payment by credit card for the month's charges if payment is not received by the 15th of the following month- statements are sent out on the 1st of each month. Upon cancellation of membership, wine and cigars must be removed within 30 days or they become the property of Eddie Matney's.)

For Office Use Only:
Account #_______ Wine Locker #________ Humidor #_________