First and Last Name

Email Address

Phone Number

Date/Time of Visit

Date/Time of Visit: Date

Date/Time of Visit: Time

Restaurant Visited

- None -Ada, OhioBeaverdam, OhioBluffton, OhioBucyrus, OhioCarey, OhioDelphos, OhioHicksville, OhioGalion, OhioKenton, OhioLima, Ohio — Elida RdLima, Ohio — N West StLima, Ohio — Harding HwyLima, Ohio — Shawnee RdLima, Ohio — Cable RdLima, Ohio — Market StOttawa, OhioUpper Sandusky, OhioVan Wert, Ohio — Shannon StVan Wert, Ohio — Christopher Cr

Description of the Visit/Issue

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