First Name
Last Name
Street Address
City
State
Zip Code
Email
Phone
Birthday
Month
Day
Yes, I want to join Millie’s Best Guest Club.
Millie’s Store Visited
Choose One
Anaheim
Brea
Covina
Fontana
Hemet
La Mirada
Mission Hills
Simi Valley
Van Nuys
Walnut
1. Day of Visit
Time of Visit:
2. Including this visit, how many times in the past three months have you visited any Millie's?
3. Please rate us on the following attributes
("1" represents Very Poor and "5" represents Excellent).
Taste of food
1
2
3
4
5
Speed of service
1
2
3
4
5
Courteous service
1
2
3
4
5
Price of menu items
1
2
3
4
5
Variety of menu items
1
2
3
4
5
Portion size
1
2
3
4
5
Cleanliness
1
2
3
4
5
Overall value for the money
1
2
3
4
5
4. Are you Male or Female?
Male
Female
5. In which of the following age groups do you belong?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
General Comments:
This information is for the exclusive use of Millie's Restaurant & Bakery and
will not be sold or shared.