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Fill out the form below to join our Birthday/Email Club and receive a Birthday Card with an offer for a complimentary Appetizer or bottle of wine* when you come in and dine at Sam Seltzer's during the month of your Birthday.

*Must be 21 years or older.

Name*:
Email*:
Birthdate*:	January February March April May June July August September October November December
Address:*
City:*
State:*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:*
Location:*	Select a restaurant location Tampa Brandon Clearwater Altamonte Lakeland Sarasota Port Richey Ft. Myers St. Petersburg Port Charlotte
* indicates a required field.