Satisfaction Survey

How satisfied were you?♦ Using the following scale, please rate your satisfaction:

Would you refer this restaurant to a friend?

Yes     No

Please explain your ratings. Your suggestions, compliments or service ideas are very important.

Who was your server? Please leave blank if you do not know.

What was the date of your visit?

If you are not sure, please leave blank. January February March April May June July August September October November December 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 2006 2007 2008 2009 2010

Which meal did we provide for you?♦

Please Select: Breakfast Lunch Dinner Appetizer Dessert Other

Which services did you use? Check one or more.

Restaurant Bar

How often do you dine here?

First visit Second visit Occasionally Once a Month Two to three times a month Once a Week Two to three times a week Four to more times a week

Your information is safe and will not be shared with or sold to a third-party. In addition, your information will only be used for the purposes listed below with your expressed permission, or to follow up regarding your survey comments.

Please enter your information and be sure to press the Complete Survey button to submit your information. Once you have done this you will be entered into the monthly drawing for a $100 gift card.

First Name

Last Name

Address

City

State

Zip Code

Would you like to receive mailed special offers such as vouchers and discounts, some of which maybe for your birthday?

If yes, select the month of your birth, below. Yes    No

Please indicate the month of your birth.

Would you like to receive an occasional e-mail or mailing from this restaurant? (Special event invitations, discount offers, menu changes, etc.) If yes, fill in your email address, below.

Yes    No

Email Address