* Required fields

First Name:*

Last Name:*

Email:*

Address:*

-- Please Select -- 1-3 4-6 Haven't How many times per month do you dine with us?*

-- Please Select -- Online Take-out Third Party Delivery How do you order?*

Any dietary needs?*

-- Please Select -- Seafood Pork Beef Shellfish Poultry Which protein do you prefer?*

Which vegetable do you NOT prefer?*

Which spice do you NOT prefer?*

Any dietary needs?*

-- Please Select -- Chocolate Non-chocolate Do you prefer chocolate or non-chocolate desserts?*

-- Please Select -- Yes No Do you enjoy a cocktail at dinner?*

-- Please Select -- White Red Rose Sparkling Wine preference?*

Beer choices?*


Thank you for your support in 2021! Eddie Bernal and 34th Street Cafe & Santa Rita Teams!!