First Name * Last Name *

Street Address * Apt / Suite / etc
City * State * Zip Code *

Email Address *

Confirm Email Address *

Phone Number or Numbers *
These will be used in place of a physical card if
you don't have your card at the time of purchase. 		Number of People in Household *
() -
() -
() -

Birthday * Wedding Anniversary
/ / / /

Spouse's First Name Spouse's Last Name

Spouse's Email Address

Confirm Spouse's Email Address

Spouse's Birthday
/ /

Are you a member of a particular club? (please enter name of club)
Were you refered by an employee of La Gra Italian Tapas? (please enter employees name)

Referral Code

Clerk Number


We are firmly committed to your privacy and the protection of your information. We will NEVER share, sell or rent individual personal information with anyone without your advance permission.

The emails you receive from us will include regular email communication notifying you of specials offers, events, point balances, and promotions, sent to you on behalf of La Gra Italian Tapas from Empower Marketing (rewards@myrewardsprogram.net).

Privacy Policy


* an asterisk denotes a required field

Once you submit, your Phone Number will serve as your card number
**No card will be necessary**