SCRIP ORDER FORM - School Webmasters

SCRIP ORDER FORM

SCRIP-TO-GO: IN STOCK AND AVAILABLE TODAY

COMPLETE THIS FORM

and submit with payment

DATE:_____ NAME:_________________ *CHECK (check #________) * CASH

* RECEIVING YOUR SCRIP: I WILL PICK UP THE CARDS

FROM THE OFFICE

*SEND CARDS HOME WITH MY STUDENT _____________________

HOMEROOM TEACHER________________________________

BUSINESS

SCRIP NOW or PROFIT

RELOAD AVAILABLE

CARD VALUE

QTY

Total $$

RCV'D ?

Copps/ Roundy's/ Pick n Save

x

4%

50 100

$ $

HyVee

5%

50 100

$ $

GROCERY

Sentry (paper SCRIP)

3% 50

$

Whole Foods

X 3% 100

$

Willy Street Coop

9% 50

$

Woodman's

5% 50

$

100

$

Amazon

x 3% 25

$

Barnes & Noble

x 9%

5 10

$ $

Bed Bath & Beyond

7% 25

$

Dick's Sporting Goods 8% 25

$

RETAIL / SERVICES

Gap/ Banana Republic x 14% 25

$

Old Navy/ Athleta

Great Clips

8% 25

$

Home Depot

x 4% 25

$

Klinke's Cleaners

10% 25

$

Kohls (can pay charge card bill)

x

4%

25 100

$ $

Marshalls/TJ Maxx/Home Goods

x 7% 25

$

Menards

3% 25

$

Petsmart

4% 25

$

Pottery Barn/ West Elm/ William Sonoma

x 8%

25

$

REI

x 8% 25

$

Shopko

3% 25

$

Staples

x 5% 25

$

Target

x 2.5%

25 50

$ $

Walgreens

6%

25 100

$ $

Wal Mart

x 2.5% 25

$

Marcus Theatres

9% 25

$

AMC Theatres

x 7% 25

$

Vitense Golf Land

10% 10

$

iTunes

x 5% 15

$

BUSINESS

SCRIP NOW PROFIT

or RELOAD AVAILABLE

CARD VALUE

QTY

Total $$

RCV'D ?

BP

x 1.5% 50

$

25

$

Kwik Trip

4% 50

$

GAS

100

$

PDQ

5% 50

$

Bonefish Grill/ Outback / Flemings

8% 25

$

Buffalo Wild Wings x 8% 25

$

Cheesecake Factory

5% 25

$

Chili's

x 11% 25

$

Chipotle

x 10% 10

$

Culvers

10% 25

$

Dunkin' Donuts

3% 10

$

Einstein Bagels

10% 10

$

RESTAURANT

Food Fight Restaurants 10% 25

$

Madison Originals Group 15% 25

$

Milio's

10% 10

$

Noodles & Company

8% 10

$

25

$

Olive Garden/ Red Lobster x 9% 25

$

5

$

Panera Bread

x 9% 10

$

25

$

Papa Murphy's

x 8% 10

$

Pizza Hut

x 8% 10

$

Rocky Rococo's

10% 20

$

Subway

x 6% 10

$

Starbucks

5

$

x 7% 10

$

25

$

TOTAL FROM THIS SIDE

$

TOTAL OTHER SIDE (SPECIAL ORDERS) $

ORDER TOTAL

$

OFFICE USE

* * ORDER Complete

Incomplete

FILLED BY: :________

* Order Entered

ENTERTAINMEN

If this is your first order for the year, please complete the additional information in the boxes below

REGISTRATION INFORMATION:

YOUR REBATE: 60% of your earned rebate automatically goes to

support School & Family. Each SCHOOL YEAR you

PHONE________________

may select a designation for the other 40% of your

E-MAIL_____________________________

rebate. Indicate your choice below:

4I have read the 2014-15 SCRIP PROGRAM ______MY TUITION

______ENDOWMENT

______CMC

______SCHOOL & FAMILY

_____ YOUTH MINISTRY

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