90 Day Restaurant Challenge
Melinda's
Date
-
Month
-
Day
Year
Date
Name of Restaurant
Number of Locations
Restaurant Address or HQ Address (if multiple locations)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Name of Entity that Owns Restaurant
First Name
Last Name
Number of Years in Business
Point of Contact Information
First Name
Last Name
Position/Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Cuisine
Product(s) Selected for Trial (select all that apply)
Fire Roasted
Green
Mexicana
Louisiana
Sriracha
Pizza
Ghost Pepper
Black Truffle
Estimated Number of Bottles Needed Per Location for Fire Roasted if selected?
Estimated Number of Bottles Needed Per Location for Green if selected?
Estimated Number of Bottles Needed Per Location for Mexicana if selected?
Estimated Number of Bottles Needed Per Location for Louisiana if selected?
Estimated Number of Bottles Needed Per Location for Sriracha if selected?
Estimated Number of Bottles Needed Per Location for Pizza if selected??
Signature of Authorized Representative
Submit
Should be Empty: