Coupon Request Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Have you dined at any Manuel's Mexican Restaurant?*YesNoDid you receive a package in the mail promoting these coupons?*YesNoWhat business do you work at?*How many people work in your office?*Do you ever order food to be delivered to your office?*YesNoWho do you order from most often?*CaptchaPhoneThis field is for validation purposes and should be left unchanged.