SCRIP ORDER FORM
Name: ___________________________ Phone: ______________ Date: _________
|
Retailer |
Amount | % |
Order |
Retailer |
Amount | % |
Order |
| Grocery | Dept. Stores | ||||||
| Buehler's Buy-Low | $10-$50 | 5% | Build-A-Bear | $25 | 8% | ||
| Schnucks | $25/$100 | 5% | Children's Palace | $25 | 12% | ||
| Wesselmans | $10/$20 | 5% | Claire's | $10 | 9% | ||
| Dick's Sporting Goods | $25 | 8% | |||||
| Restaurants | Dillard's | $25 | 8% | ||||
| Acropolis | $25 | 10% | Disney | $25/$100 | 2% | ||
| Applebee's | $25 | 8% | Gander Mtg. | $25 | 8% | ||
| Arby's | $5 | 10% | JC Penny's * | $25 | 5% | ||
| Baskin Robins | $2 | 9% | Kohl's * | $10-$100 | 5% | ||
| Biaggi's | $25 | 10% | Land's End | $25 | 9% | ||
| Bob Evans | $10 | 10% | Macy's | $25 | 9% | ||
| Burger King | $10 | 8% | Marshall's/T.J. Maxx | $25 | 7% | ||
| Chili's | $20 | 11% | Old Navy / Gap | $25 | 9% | ||
| Chuck E. Cheese | $10 | 8% | Payless Shoes | $20 | 13% | ||
| Cork N Cleaver | $25 | 10% | Sears | $25-$100 | 4% | ||
| Cracker Barrel | $10 | 9% | Shoe Carnival | $25 | 5% | ||
| Culvers | $10 | 15% | ToysRUS/KidsRUs | $20 | 1.5% | ||
| Denny's | $10 | 7% | |||||
| Domino's Pizza | $5 | 5% | |||||
| Fazoli's | $25 | 7% | |||||
| G.D. Ritzy's | $5 | 15% | |||||
| GFS Market Place | $25 / $100 | 4% | |||||
| Golden Corral | $25 | 3% | |||||
| Great Harvest Bread | $10 | 8% | |||||
| Hacienda | $10 | 10% | |||||
| Lic's | $2 | 15% | |||||
| Logan's Roadhouse | $25 | 8% | Entertainment Electronics | ||||
| Long John Silver's | $5 | 9% | Blockbuster Gift Card | $10 | 7% | ||
| Longhorn Steakhouse | $25 | 11% | Blockbuster Single Rental | $3.79 | 15% | ||
| Max & Ermas | $20 | 13% | Premier Video | $20 | 25% | ||
| Nick's Pizza & Wings | $10 | 20% | Best Buy | $25/$100 | 2% | ||
| O'Charley's | $25 | 13% | Circuit City | $25 / $100 | 3% | ||
| Old Chicago Pizza | $25 | 6% | Walther's Golf | $11.50/$12.00 | 10% | ||
| Outback Steakhouse/Bonefish Grill/Cheeseburger in Paradise | $25 | 4% | |||||
| Panara Bread | $10 | 9% | Home Improvement | ||||
| Pizza Hut | $10 | 9% | Lowe's | $25/$100 | 4% | ||
| Home Depot | $25/$100 | 3% | |||||
** N/A - not available at this time
SCRIP ORDER FORM
Name: ___________________________ Phone: ______________ Date: _________
|
Retailer |
Amount | % |
Order |
Retailer |
Amount | % |
Order |
| Restaurants | Automotive | ||||||
| Red Lobster OliveGarden | $25 | 9% | Thortons | $25/$50/$100 | 2% | ||
| Starbucks | $10/$25 | 7% | |||||
| Subway | $10 | 7% | Miscellaneous | ||||
| TCBY | $5 | 25% | CVS Pharmacy | $25 | 2% | ||
| Texas Road House | $25 | 8% | Walgreens | $20 | 2% | ||
| TGI Fridays | $25 | 8% | Jo Ann Fabrics | $20 | 6% | ||
| Porter Paints | $25 | 10% | |||||
| Wendy's | $10 | 10% | |||||
| Books / Stationary | |||||||
| Barnes & Noble | $10/$25 | 9% | |||||
| Borders / Waldenbooks | $10/$25 | 8% | |||||
|
Staples |
$25 | 5% | |||||
| Office Depot | $25 | 4% | |||||
| Family Christian | $10 | 9% | |||||
| Gifts, Etc. | |||||||
| Bath & Body Works | $10/$25 | 13% | |||||
| Bed, Bath & Beyond | $25 | 7% | |||||
| Linens 'N Things | $25 | 8% | |||||
| TOTAL ORDER | |||||||
| Cash / Check # | |||||||
* Can be used to pay credit card balance
SCRIP Coordinators: Kathy Seay and Pam Sauls