Registration
Complete the information below to register for the Platinum Club.
Name:
Company Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Work Phone:
Home Phone:
Birthday:
Anniversary:
Email Address:
Location:
- Select Location -
Indianapolis
Fort Wayne
Cincinnati
Columbus
Would you like to receive information and/or invitations to special events?
Yes
No
How often do you visit Eddie Merlot's?
First Visit
Less than once a month
Once a month
2-3 times a month
4 times a month or more
Would you like to receive information/communications from Eddie Merlot's via e-mail?
Yes
No
