Customer Information:
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:

How often do you visit Brown's?
	Regularly (Once a week or more on average) Frequently (Less than once a week on average) Occasionally (Once a month or less on average) First Time Visit
Date of most recent visit:
	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 2010 2009 2008 2007 2006
Approximate time of visit:
	:   AM PM
Location visited:
	Arlington Heights, IL (3441 N. Arlington Heights Rd.) Bensenville, IL (511 W. Irving Park Rd.) Bolingbrook, IL (439 N. Bolingbrook Dr.) Bridgeview, IL (8719 S. Harlem Ave.) Burbank, IL (8300 S. Cicero Ave.) Chicago, IL (6909 W. Archer Ave.) Chicago, IL (5601 W. Lawrence Ave.) Chicago, IL (7859 S State St.) Chicago, IL (6659 S. Wentworth Ave.) Chicago, IL (4359 N. Pulaski Rd.) Chicago Heights, IL (600 S. Halsted St.) Countryside, IL (5801 S. La Grange Rd.) Downers Grove, IL (236 Ogden Ave.) East Dundee, IL (529 Dundee Ave.) Evergreen Park, IL (3414 W. 95th St.) Frankfort, IL (320 La Grange Rd.) Highland, IN (8845 Indianapolis Blvd.) Highland Park, IL (2566 Skokie Valley Rd.) Hoffman Estates, IL (1059 W. Golf Rd.) Homer Glen, IL (14226 S. Bell Rd.) Joliet, IL (2301 W. Jefferson St.) Lockport, IL (1055 E. 9th St.) Melrose Park, IL (1500 W. North Ave.) Midlothian, IL (3721 W. 147th St.) Mt. Prospect, IL (950 E. Rand Rd.) Naperville, IL (660 S. Washington St.) Northbrook, IL (3147 Dundee Rd.) Oak Lawn, IL (4740 W. 111th St.) Orland Park, IL (14450 La Grange Rd.) Palatine, IL (301 E. Northwest Hwy.) Palos Hills, IL (8831 W. 95th St) Prospect Heights, IL (1206 N. Elmhurst Rd.) Round Lake Beach, IL (714 E. Rollins Rd.) Skokie, IL (3949 Oakton St.) Tinley Park, IL (6801 W. 159th St.) Waukegan , IL (3150 Belvidere Rd.) Wheaton, IL (1 N. 058 Main St. )
Items ordered:
	Chicken Pasta Side Choices Mushrooms Sandwiches Seafood
	Other:
Favorite menu item(s):
Item(s) you'd like added to our menu:
Please rate the categories below:
	Food Quality: Make Selection Excellent Good Fair Poor Does Not Apply Food Taste: Make Selection Excellent Good Fair Poor Does Not Apply Value: Make Selection Excellent Good Fair Poor Does Not Apply Speed of Service: Make Selection Excellent Good Fair Poor Does Not Apply Friendliness of Employee(s): Make Selection Excellent Good Fair Poor Does Not Apply Restaurant Appearance: Make Selection Excellent Good Fair Poor Does Not Apply Restaurant Cleanliness: Make Selection Excellent Good Fair Poor Does Not Apply
Will You be returning to Brown's?
	YesNoUndecided
Would you recommend Brown's to friends and family?
	YesNoUndecided
Have you recently (within last 2-3 months) seen any Brown's television commercials?
	YesNo
What television service do you currently subscribe to?
	Comcast RCN Wide Open West Dish Network Direct T.V. None
Additional comments: (Your comments in this box may be posted on the testimonial sections on our website)