Loyalty Discount Application

Please read the TERMS & CONDITIONS carefully before filling up the form.

* Denotes required fields

Reward Application*
Basic - $9.95Premium - $19.95 (limited)
Loyalty Act#
Date of Purchase
 
Name*
Date of Birth*
Current Address* (if lost or stolen)
Email Address*
Phone Number* (to look up account)
 
How Many Chimichangas do you eat on a Monthly Basis?*
Would you prefer gifts or free food?*
GiftsFree Food
Credit Card*
VisaMastercardAmerican ExpressDiscover
Please FAX the following credit card information to (812) 339-2340
(1.) Name on Card (2.) Card Number (3.) Exp month (4.) Exp year (5.) CVV code
 
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