SCRIP Order Form
SCRIP Order Form
Name Check #
Sears $25
**6.00%
% QTY
7.00% 10.00% 16.00% 9.00% 8.00% 10.00% 10.00% 6.00% 10.00% 9.00% 14.00%
Total
$ $ $ $ $ $ $ $ $ $ $
Total
$
% QTY
**10.00 % **10.00 % 8.00% 10.00% 12.00% 8.00% 8.00% 5.00% 11.00% 8.00% 9.00% 9.00% 9.00% 8.00% 8.00% 13.00% 8.00% 8.00% 9.00% **11.00 % 8.00% 8.00% 9.00%
Total
$ $ $ $ $ $ $ $ $ $
% QTY
8.00% 4.00% 10.00% 8.00% 8.00% 7.00% 6.00% 7.00% 8.00% 8.00% **10.00 % **10.00 % 8.00% 8.00% 7.00% 10.00% 7.00% 7.00% 8.00% 3.00% 5.00% 5.00% 4.00%
Total
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $
Cracker Barrel $10 Cracker Barrel $25 Landry's Restaurants $25 Logan's Roadhouse $25 Noodles & Company $10 O'Charley's $25 Olga's Kitchen $20 Outback $25 Red Lobster/Olive Garden $25 Red Robin $25 Ruby Tuesday's $25 Texas Roadhouse $25 TGI Friday's $25
$ $ $
$ $ $ $ $ $ $ $ $ $ Papa John's Pizza $10 Pizza Hut $10 Qdoba $25 Quiznos $10 Starbucks $10 Starbucks $25 Steak 'n Shake $10 Subway $10 Taco Bell $10 Tim Hortons $10 Wendy's $10
Payless Shoes $20 13.00% Talbots $25 The Children's Place $25 TJ Maxx/Marshalls/Ho meGoods $25 13.00% 12.00% 7.00%
% QTY
5.00% 4.00% 10.00%
Total
$ $ $
**Limited time bonus offer. Participating retailers and products are subject to change without notice.
Name Check #
1.50% 1.50% 1.50% 8.00% 3.00% 3.00% 2.50% 2.50% 4.00% 4.00% 1.50%
$ $ $ $ $ $ $ $ $ $ $
% QTY
4.00% 4.00% 2.00% 2.00% 2.00% 2.00%
Total
$ $ $ $ $ $
Chevron $50 Exxon/Mobil $50 Jiffy Lube $30 Marathon $25 Marathon $100 Shell $25 Shell $50 Speedway $100 Speedway $25
% QTY
4.00% 4.00% 4.00% 4.00% 4.00% 4.00%
Total
$ $ $ $ $ $
% QTY
4.00% 4.00% 7.00% **10.00 % **10.00 % **17.00 % 12.00%
Total
$ $ $ $ $ $ $ $ $
% QTY
3.00% 3.00% 4.00% 5.00% 4.00%
Total
Sunoco $50 $
Grocery
$
Product
$ $ $ Gordon Foods Service Marketplace $25 Gordon Foods Service Marketplace $100 Meijer $25 Meijer $50 Meijer $100 $
% QTY
4.00%
Total
$
4.00%
$ L.L.Bean $25
Entertainment Product
AMC Theatres/Loews Cineplex $25 AMC Theatres/Loews Cineplex Single Ticket $9.50 Barnes & Noble $10 Barnes & Noble $25 Dave & Buster's $25
% QTY
**12.00 % 16.00%
Total
$
$ $ $
Nike $25
Service Total
$ $ $ $
Product
Regis Salons $25
% QTY
8.00%
Total
$
$ $ $
Bed Bath & Beyond $25 Crate & Barrel $25 Pier 1 $25 Pottery Barn / Williams-Sonoma $25 Pottery Barn / Williams-Sonoma $100
Bath & Body Works 13.00% $10 Bath & Body Works 13.00% $25 Build-A-Bear Workshop $25 CVS/pharmacy $25 8.00% 6.00%
% QTY
7.00% 8.00%
Total
$ $
8.00%
**Limited time bonus offer. Participating retailers and products are subject to change without notice.
Name Check #
Family Christian Stores $25 GNC $25 Guitar Center $25 Hallmark $25 Honey Baked Ham $25 Jo Ann Fabrics $25 Michaels $25 PetSmart $25 Rite Aid $25 The Container Store $25 Toys R Us/Babies R Us $20 Walgreens $25
9.00% 8.00% 4.00% **5.00% 12.00% 6.00% 4.00% 4.00% 4.00% 9.00% 1.50% 6.00%
$ $ $ $ $ $ $ $ $ $ $ $
% QTY
**12.00 % 11.00% 8.00% 8.00% 8.00% 8.00% 8.00%
Total
$ $ $ $ $ $ $
Travel Product
Disney $25
% QTY
2.00%
Total
$
**Limited time bonus offer. Participating retailers and products are subject to change without notice.