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First Name:
   
 
 
 
Last Name:
   
 
 
 
Email Address
   
 
 
 
Gender
 
Male
 
Female
 
 
 
Age
 
Under 18
 
18-20
 
21-22
 
23-24
 
25-29
 
30-40
 
40-50
 
50-60
 
over 60
 
 
 
Are you currently a college student
 
No
 
Yes (Undergraduate - Community)
 
Yes (Undergraduate - University)
 
Yes (Graduate Student)
 
Prefer not to answer
 
 
 
Establishment Code:
   
 
 
 
What way(s) do you pay at this establishment?
 
Credit Card
 
Cash
 
Check

 
 
 
What day(s) of the week do you frequently visit?
 
Monday
 
Tuesday
 
Wednesday
 
Thursday
 
Friday
 
Saturday
 
Sunday

 
 
 
Please rank the following in order of interest, 1 being most interested:
Mixed drinks
Shots
Well drinks
Beer
Bottle specials
No cover
Appetizer / Meals
 
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