Origin India Restaurant

Thank you for providing your feedback about our restaurant. We value your opinion!

In return for your completion of this questionnaire, we will email you a $10 gift certificate to use at your next visit to Origin India. (All information submitted will not be passed on to any 3rd party.) You will also receive special birthday and anniversary gift certificates as part of our Email VIP Club.

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First Name*
Last Name*
Company
Address
City
US State
Zip Code*
Birthday	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 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
Spouse's Birthday	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 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
Anniversary	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 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
How did you hear about us?	Previous Visit Personal Recommendation Advertisement Other
What attracted you to this restaurant?	Food Value Price
How often do you visit our restaurant?	Occasionally Often Regularly
When do you visit?	Lunch Dinner Late Night
Please rate the following on a scale of 1-10 (10 being excellent)
Value for the money	1 2 3 4 5 6 7 8 9 10
Quality of Food	1 2 3 4 5 6 7 8 9 10
Atmosphere	1 2 3 4 5 6 7 8 9 10
Interior/Decor	1 2 3 4 5 6 7 8 9 10
Our Staff	1 2 3 4 5 6 7 8 9 10
Service	1 2 3 4 5 6 7 8 9 10
How likely are you to visit again?	1 2 3 4 5 6 7 8 9 10
Comments
* indicates mandatory field I would not like to receive future promotional email messages,exclusive invitations and special birthday and anniversary discounts.
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