Parasole Dining Club member request form
Title:
Mr
Mrs
Ms
Miss
Dr
Rev
Sr
Full Name:
Phone Number:
Email Address:
Dining Club Account Number:
Date of Visit: (dd/mm)
Store Visited:
Select Location
Burger Jones - Burnsville
Burger Jones - Calhoun
Chino Latino
Good Earth - Edina
Good Earth - Roseville
Libertine
Manny's Steak House
Pittsburgh Blue - Edina
Pittsburgh Blue - Maple Grove
Salut Bar Americain - France Ave
Salut Bar Americain - Grand Ave
The Living Room/Prohibition
Receipt Number:
Amount:
Comments:
Send me a replacement card:
*
*
Must be within the last thirty days.
Please allow up to ten business days for delivery of replacement card.
Please type the text as it appears in the company logo below: