SCRIP ORDER FORM
Revised 5-16-17
Family Name________________________________________ Home Phone Number____________________
Date__________________________________________
Cell Phone Number _____________________
Grocery Stores
Circle Denom. Qty Sum
♥Copp’s – 4%
$♥25/♥50/100
____ ____
I-Tunes – 5%
$15/25
____ ____
Gallaghers – 10%
$25/50/100
____ ____
Indira Salon – 10%
$25/50
____ ____
Grazies Italian Grill – 12%
$25/50
____ ____
*J.C.Penney – 5%
$25/100
____ ____
$25/50/100
____ ____
♥# Kohl’s – 5%
$10/25/50/100
♥Festival Foods – 3%
♥Maplewood Meats – 5%
♥Meijer – 3%
Retail/Department
Circle Denom. Qty Sum
$5
____ ____
____ ____
Happy Joe’s - 10%
$5
____ ____
____ ____
Hu Hot Mongolian Grill- 10%
$20
____ ____
____ ____
♥Jimmy John’s – 5%
$10
____ ____
♥Julie’s Café – 5%
$10
____ ____
♥La Java –5%
$10
____ ____
Legend’s – 10%
$5/10
____ ____
$25/50/100 ____ ____
♥Woodman’s – 5%
Lindeman Cleaners – 8%
$5/10
$50/100
♥Marcus Properties -9%
$♥25/100 ____ ____
Gas & Auto
Circle Denom. Qty Sum
BP – 1.5%
$50/100
____ ____
Exxon/Mobil - 1%
$50
____ ____
♥Grand Central Station – 10%
♥*Kwik Trip –5%
$25/50/100 ____ ____
$10/25/50/100
____ ____
Los Banditos – 5%
$10
____ ____
$25
____ ____
♥McDonald’s – 5%
$25
____ ____
Can also be used at Office Depot
PetSmart – 4%
*Sears – 4%
$25/100/250
____ ____
Moe’s Southwest Grill - 5%
$10
____ ____
____ ____
♥Shopko – 3%
$25//100
____ ____
Noodles & Co. – 10%
$10
____ ____
♥*Target – 2.5%
$♥25/♥50/100
____ ____
♥Olive Garden/Red Lobster – 8% $25
____ ____
$16/23
Shell Oil Card – 2%
$25/50/100 ____ ____
Home & Garden
Circle Denom. Qty Sum
$25/100
$25/100
____ ____
PDQ – 5%
*ACE Hardware – 4%
(Includes Theatres & Marcus Hotels & Resorts)
*Office Max – 5%
Circle Denom. Qty Sum
$25
♥Piggly Wiggly – 3%
____ ____
Restaurants
Thornberry Cottage – 5%
$10
____ ____
Panera Bread – 8%
$10/25
____ ____
____ ____
TJ Maxx/Marshalls – 7%
$25/100
____ ____
Papa Murphy’s Pizza – 8%
$10
____ ____
♥*Fleet Farm – 4%
$10/25/50/100
____ ____
*Toys ‘R Us – 3%
$20/100
____ ____
Pizza Hut – 8%
$/10
____ ____
*Home Depot – 4%
$25/100/500
____ ____
Tundra Lodge – 10%
$25/50
____ ____
Smart Cow – 5%
$10
____ ____
*Lowe’s – 4%
$25/100/500
____ ____
* Younker’s – 8%
$25/100
____ ___
Starbuck’s – 7%
$10/25
____ ____
♥*Menards – 3%
$♥25/100/500
____ ____
____ ___
♥Subway – 6%
$10/50
____ ____
Retail/Department
Circle Denom. Qty Sum
Taco Bell –5%
$10
____ ____
Texas Roadhouse - 8%
$25
____ ____
Title Town Brewing – 7%
$25
____ ____
♥Townline – 10%
$25
____ ____
*Aeropostale – 10%
$25
____ ____
*American Eagle – 10%
$25
____ ____
#Barnes & Noble/ - 8%
$10/25/100
Bath & Body/White Barn – 13%
*Best Buy – 3%
____ ____
$10/25
____ ____
$25/100/250
____ ____
Buckle – 8%
$25
____ ____
♥CVS – 6%
$♥25/♥100
____ ____
Dick’s Sporting Goods – 8%
$25/100
____ ____
Dunham’s Sports – 8%
$25
____ ____
♥Family Video – 12%
$10
____ ____
*#The Gap/Old Navy/ -14%
$25/100
____ ____
Banana Republic
♥Walgreen’s – 6%
$♥25/♥100
♥*Wal-Mart– 2.5%
$/♥25/♥100/250 ____ ____
Restaurants
Circle Denom. Qty Sum
A & W – 10%
$5
____ ____
Applebee’s - 8%
$25/50
____ ____
Arby’s – 8%
$10
____ ____
Bay Family – 10%
$25
____ ____
# - Denotes Catalog/Internet Availability
♥Breadsmith - 5%
$10
____ ____
* - CANNOT be used to pay on charge accounts!
Burger King – 4%
$10
____ ____
Grand Total
Chipotle Mexican Grill – 10%
$10
____ ____
$
Chuck E. Cheese - 8%
$10
____ ____
♥Dairy Queen (local) – 10%
$1
____ ____
♥ Dairy Queen (National) – 3%
$10
____ ____
♥Dunkin’ Donuts - 3%
$10/25
____ ____
♥ Items we keep in inventory
Seller_________________ Cash________ Check #_______
More on the back!

Miscellaneous
Circle Denom.
Qty Sum
Miscellaneous
Circle Denom.
Qty Sum
Miscellaneous
Abbey Bar – 11%
$25
____ ____
Famous Footware – 8%
$25
____ ____
Advance Auto Parts – 7%
$25
____ ____
Finish Line – 10%
$25
# Amazon.com – 2.5%
$25/100
____ ____
Footlocker – 9%
Ambrosius Studios – 3%
$25/50
____ ____
Animal House Pet Clinic/Groom
& Boarding – 3%
Circle Denom.
Qty Sum
Old Chicago – 6%
$25
____ ____
____ ____
Outback Steakhouse-8%
$25/50
____ ____
$25
____ ____
P.F. Chang’s – 8%
$25
____ ____
Game Stop – 3%
$25
____ ____
# Nike – 12%
$25
____ ____
Gippers – 5%
$10
____ ____
Papa Johns – 8%
$10
____ ____
$25
____ ____
GNC – 8%
$25
____ ____
Payless Shoes – 13%
$20
____ ____
Austin’s – 3%
$25/50
____ ____
Great Harvest Bread Co. – 6%
$10
____ ____
*Pier I Imports – 9%
$25
____ ____
Avis Car Rental – 8%
$50
____ ____
Groupon.com – 7%
$10/25
____ ____
Pizza Ranch – 10%
$10
____ ____
Bass Pro Shop – 9%
$25/100
____ ____
Gymboree – 13%
$25
____ ____
Red Robin – 8%
$25
____ ____
*Bed Bath & Beyond - 7%
$25/100
____ ____
HJ Martin – 3%
$100
____ ____
Ruby Tuesday – 8%
$25
____ ____
Best Western International – 12% $25/100
____ ____
Hardees – 5%
$10
____ ____
Sally Beauty Supply – 12%
$25
____ ____
Bops Bistro
$10
____ ____
Harmann Studios – 7%
$25
____ ____
Seroogy’s – 11%
$25
____ ____
Broadway Automotive –8%
$25
____ ____
Hilton/Hampton/Embassy 2%
$50/100
____ ____
Staples – 5%
$25/100
____ ____
Budget Car Rental – 8%
$50
____ ____
Hinterland Brewery – 6%
$50/100
____ ____
Super America Speedway – 4%
$25/100
____ ____
Buffalo Wild Wings – 8%
$10/25
____ ____
Honey Baked Ham – 12%
$25
____ ____
Superior Liquor – 5%
$25
____ ____
Build-A-Bear - 8%
$25
____ ____
Hyatt Hotel – 9%
$50/100
____ ____
*#Talbots – 13%
$25
____ ____
*#Cabela’s – 11%
$25/100
____ ____
IHOP- 8%
$25
____ ____
Taylor Creek - 8%
$25/50
____ ____
Cheesecake Factory – 5%
$25
____ ____
J. Crew – 13%
$25
____ ____
TGI Friday’s – 9%
$25
____ ____
____ ____
Jo to Go – 10%
$10
____ ____
The Bar – 5%
$20
____ ____
$25
____ ____
Children’s Place – 12%
$25
Chili’s –11%
$25
____ ____
#JoAnn Fabrics – 7%
$25
____ ____
Tony Roma’s – 12%
Claires – 9%
$10
____ ____
*K-Mart – 4%
$25/50
____ ____
Visa Universal Card 1.25% $50/100/250
____ ____
Clarion Hotels – 3%
$50/100
____ ____
*L.L.Bean – 15%
$25100
____ ____
Wendy’s – 4%
$10
____ ____
Lane Bryant – 8%
$25
____ ____
*Williams Sonoma/Pottery
$25/100
____ ____
$25/100
____ ____
$25/100
____ ____
Comfort Inn/Suites
Cold Stone Creamery – 8%
$10
____ ____
*#Lands End – 16%
Crate & Barrel – 8%
$25/100
____ ____
Lighthouse Christian Books – 5% $10
____ ____
Zappo’s – 8%
Crystal Coffee Shop – 10%
$5
____ ____
Little Caesars – 8%
$20
____ ____
# - Denotes Catalog/Internet Availability
*#Dell Computer – 4%
$100
____ ____
Mackinaw’s - 10%
$20
____ ____
Delta Airlines – 4%
___ ____
*Macy’s – 10%
* - CANNOT be used to pay on charge accounts!
$250/1000
$25/100
____ ____
Denny’s – 7%
$10
____ ____
*Maurices – 7%
$20
____ ____
Discover Card 1.25%
$50/100/250
____ ____
Michael’s Arts & Crafts – 4%
$25
____ ____
Disney – 2%
$25/100/1000
____ ____
Moes Vision - 15%
$25
____ ____
Domino’s Pizza –8%
$10
____ ____
Dress Barn – 8%
$25
____ ____
Eddie Bauer – 10%
$25
____ ____
*#Express - 10%
$25
____ ____
Barn - 8%