If you would like to be included on the Maxxium Hong Kong Ltd. database and receive regular information on special offers, new price lists etc.,please leave your name, contact numbers, email and postal address here:

Maxxium Direct - Member Enrollment Form

Customers Contact
	Mr   Mrs   Ms
Last Name* :	First Name*
Home Address :
Office Address :
Tel No. :	Mobile No. :
Fax No. :
E-mail Address* :
Referral Code :
Personal Detail (Optional)
Age :	20 ~ 30   30 ~ 40   40 ~ 50   50+
Income :	$10,000 Below   $10,000 + $20,000 +   $30,000 + $40,000 +
Profession :
Wine Preference (Can be more than one)
Red Wine White Wine Champagne     Bordeaux Burgundy Other French Italian Spanish German Californian Chilean Australian South African New Zealand
Your Favorite Wine :
Member Benefit
* Special Discount * Free Gift with Purchase * Join our wine tasting for free * Join our wine dinners at special rate * Receive wine information

* denotes mandatory fields