Autism Aware Fare 2010

Restaurant Information Form

Thank you very much for your interest in Autism Aware Fare. Please fill out the form below as completely as possible so we can add your information to our website and collateral for the event.

( * ) Denotes Required fields

Restaurant Information

*	Your Restaurant Name:
	Your Company Website:
	Your Company Logo:
		(Logo must not be bigger than 5MB.)
*	Multiple Participating Locations?	Yes No

Number of Participating Locations:

*	Street Address:
	Suite / Unit No:
*	City:
*	State:
	Zip Code:
	Phone:	(e.g. 555-555-5555)
	Single-Line Location Description:	(e.g. "The Shops at Piper Glen", "University Area", etc. Must be less than 30 characters.)

	Number of Seatings (combined, all locations):
	Number of Tables (combined, all locations):
	Desired Promotional Items:
	Open for Breakfast?	Yes No
	Open for Lunch?	Yes No
	Open for Dinner?	Yes No

Please also furnish the information below so we can contact you:

Personal Information

*	Your Name:
	Your Title:
*	Company Mailing Address:
	Apt / Suite No.:
*	City:
*	State:
*	Zip Code:
*	Your Phone:	(e.g. 555-555-5555)
	Fax:	(e.g. 555-555-5555)
*	Your Email:
		Please any additional information below:

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