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Home Style Restaurant Take Out Order Form
Pickup
Date & Time of Pickup*
 
Order No

Phone*

Email*

APPETIZERS & SIDES
Onion Rings
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Mozzarella Sticks
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Fried Pickle Chips
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Breaded Mushrooms
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Sweet Potato Fries
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Fresh Cut French Fries
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Tater Tots
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Baked Potato
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Loaded Baked Potato
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Side Dishes
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Sweet Potato Wedges
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Nacho Beef Platter
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STEAKS & SEAFOOD
8 oz. Top Sirloin
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10 oz. KC Strip
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14 oz. Ribeye
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Steak & Shrimp
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Fried Jumbo Shrimp
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21 pc. Shrimp Dinner
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Fresh Chopped Steak
 Add to Cart
BURGERS
Hamburger
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Cheeseburger
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Bacon Cheeseburger
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Mushroom Swiss
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Patty Melt
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The Western Burger
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SANDWICHES
Hand Breaded Tenderloin
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Grilled Pork Tenderloin
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Grilled Reuben
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Hot Ham & Cheese
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BBQ Pulled Pork
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Philly Steak Melt
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Chicken Philly
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Grilled Chicken Breast
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Breaded Chicken Breast
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Chicken Bacon Ranch
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Country Ham Sandwich
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Grilled Cheese
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Classic BLT
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Club Sandwich
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Chicken Wrap
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DINNERS
Chicken Fried Steak
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2 pc. Chicken Dinner
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Chicken Tenders
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Country Ham Dinner
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Hot Beef Sandwich
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Chicken Fried Chicken
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Hot Pork Tenderloin
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SALADS
Grilled Chicken Salad
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Breaded Chicken Salad
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Chef Salad
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KIDS MENU
2 Chicken Tenders
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Grilled Cheese
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5 Mini Corn Dogs
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2 Garlic Toast Mini Pepperoni Pizzas
 Add to Cart
Peanut Butter & Jelly Sandwich
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Popcorn Shrimp
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DESSERTS
Dessert
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Bowl of Ice Cream
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DRINKS
Soft Drinks
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Fresh Brewed Iced Tea
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Lemonade
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Coffee
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Hot Chocolate
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White Milk
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Chocolate Milk
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Billing Information
First Name:*

Same name as on your card
Middle Initial:

Last Name:*

Address Line 1:*

Where your statement is mailed
Address Line 2:

Apt. or Suite No.
City:*

State:*

Zip Code:*

Payment Information
Payment Method:*
Credit Card PayPal 

Card Number:*

No dashes or spaces please
Expiration Month:*

From your card
Expiration Year:*

From your card
Card Brand:*

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