.rsform-submit-button, .rsform-button { padding: 5px; background-color: #000; height: 28px; color: #F2F3E3; /* cream */ -webkit-border-radius: 4px 4px; } .rsform-submit-button:hover, .rsform-button:hover { padding: 5px; background-color: #A4B87E; /* green */ height: 28px; color: #F2F3E3; /* off-white */ -webkit-border-radius: 4px 4px; }

Become a Preferred Customer of The Veranda restaurant by filling out the short questionnaire below. You will then be informed when we have special events, entertainment, menus and wines featured at the restaurant for your enjoyment.

Please give us some information about you: 

 

Become a Preferred Customer

Your Name(*)
Please let us know your name.

Address(*)
Please provide your address

Address 2
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City(*)
Please enter your city

State(*)
Please enter your State

Zip Code(*)
Please enter a valid zip code

Telephone(*)
please enter your phone # in this format: 123-456-7890

Your Email(*)
Please let us know your email address.

Birthday (MM/DD)(*)
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How often do you dine with us?(*)
How often do you dine with us?

Date of Last Visit(*)
When did you last dine with us?

Lunch or Dinner(*)
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Servers Name
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What is your favorite entree?(*)
Tell us your favorite entree

Please rate us - 1=Low and 5=High
The quality of our food?(*)
rate our food

The quality of our service?(*)
rate our food

The ambiance of our restaurant?(*)
rate our food

Your overall satisfaction with your dining experience?(*)
rate our food

Message(*)
Please let us know your message.

If applicable, please answer the following:
Spouse's Name
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Spouse's Birthday (MM/DD)
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Anniversary (MM/DD)
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