C:\Documents and Settings\Owner\My Documents\SCRIP form

SCRIP ORDER FORM
Purchase these popular gift cards and certificates at face value and earn money for our school.
Percentages indicate the tax-deductible contribution you make to the school with your purchase!
Questions? Contact Barbara Wong: [email protected] or 860-445-0611
12-13:Nov
Name:_________________________________________________________Order Date:_______________________
Phone: _______________________________________ E-mail: ___________________________________________
Delivery method (check one): ‘ Pick up at school office
‘ Send home in backpack ** Student: _____________________ Grade: ________
** A signed liability waiver must be on file in the scrip office for backpack delivery.
Type of Order:
‘ One-time order
Orders placed by Friday will be delivered by the following Friday.
‘ Recurrent Order
‘ Initial
‘ Change existing order
Delivery Schedule:
‘ Weekly – delivery every Friday
‘ Bi-Weekly – delivery on Friday following the 1st and 15th
‘ Monthly – delivery on First Friday of the Month
OFFICE USE ONLY: Paid __________________ Data Entry__________________ Delivery _______________
Your order resulted in a contribution of ______________to our school. THANK YOU.
Product
Cost
%
Qty
Total
Product
Grocery/pharmacy
Cost
%
Qty
Total
Clothing
Big Y
$ 25.00
6%
$
American Eagle
$ 25.00
9%
$
Big Y
$ 50.00
6%
$
Brooks Brothers
$ 25.00
16%
$
Big Y
$ 100.00
6%
$
Burlington Coat Factory
$ 25.00
8%
$
ShopRite
$ 25.00
4%
$
Casual Male XL
$25.00
9%
$
ShopRite
$ 100.00
4%
$
Catherine’s (Fashion Bug)
$ 25.00
6%
$
Stop & Shop/Giant Foods
$ 25.00
4%
$
Champs Sports/Footlocker
$ 25.00
9%
$
Stop & Shop/Giant Foods
$ 100.00
4%
$
Children’s Place
$ 25.00
12%
$
Whole Foods
$ 25.00
3%
$
Dress Barn
$ 25.00
8%
$
Whole Foods
$ 100.00
3%
$
Eddie Bauer
$ 25.00
9%
$
CVS Pharmacy
$ 25.00
6%
$
Express
$ 25.00
13%
$
GNC
$ 25.00
8%
$
Fashion Bug
$ 25.00
6%
$
Walgreens
$ 25.00
2%
$
Foot Locker
$ 25.00
9%
$
Gap/Banana Rep./Old Navy
$ 25.00
9%
$
Gymboree
$ 25.00
13%
$
Gas
Gulf Oil
$ 25.00
2%
$
Exxon/Mobil
$ 50.00
1.5%
$
Exxon/Mobil
$ 250.00
2%
$
Shell
$ 25.00
2.5%
$
Shell
$ 100.00
2.5%
$
Sunoco
$ 50.00
1.5%
$
Sunoco
$ 250.00
2%
$
Texaco
$ 25.00
2%
$
Home Improvement/Housewares
Crate & Barrel
$ 25.00
8%
$
Home Depot
$ 25.00
3%
$
Home Depot
$ 100.00
3%
$
Home Goods
$ 25.00
7%
$
Lowe’s
$ 25.00
4%
$
Lowe’s
$ 100.00
4%
$
Pottery Barn
$ 25.00
8%
$
Pottery Barn
$ 100.00
8%
$
Pier 1
$ 25.00
9%
$
Williams-Sonoma
$ 25.00
8%
$
Williams-Sonoma
$ 100.00
8%
$
Justice
$25.00
6%
$
Land’s End
$ 25.00
19%
$
Limited
$25.00
9%
$
LL Bean
$ 25.00
17%
$
Marshalls/TJ Maxx
$ 25.00
7%
$
Men’s Wearhouse
$25.00
8%
$
Old Navy/Gap/Banana Rep.
$ 25.00
9%
$
Payless Shoes
$ 20.00
13%
$
Talbots
$ 25.00
11%
$
Zappos
$25.00
7%
$
Internet Shopping
1-800-Flowers
$ 10.00
25%
$
Amazon.com
$ 25.00
4%
$
American Girl
$25.00
9%
$
Bedandbreakfast.com
$ 50.00
10%
$
Disney
$ 25.00
2%
$
Groupon
$ 25.00
7%
$
iTunes
$ 15.00
4%
$
Restaurant.com – $50 value
$ 20.00
50%
$
Shutterfly
$ 25.00
9%
$
Department Stores/Super Stores
Restaurant/Fast Food/Coffee
Applebee’s
$ 25.00
9%
$
Bloomingdales
$ 25.00
12%
$
Boston Market
$ 10.00
12%
$
Bloomingdales
$ 100.00
12%
$
Buca di Beppo
$ 25.00
8%
$
Christmas Tree Shops
$ 25.00
7%
$
Burger King
$ 10.00
4%
$
JC Penney
$ 25.00
5%
$
California Pizza Kitchen
$ 10.00
4%
$
JCPenney
$ 100.00
5%
$
Cheesecake Factory
$ 25.00
5%
$
Kohl’s Department Store
$ 25.00
4%
$
Chili’s
$ 25.00
11%
$
Kohl’s Department Store
$ 100.00
4%
$
Chuck E Cheese
$ 10.00
8%
$
Macy’s
$ 25.00
10%
$
Cold Stone Creamery
$ 10.00
8%
$
Sears
$ 25.00
4%
$
Cracker Barrel
$ 10.00
9%
$
Sears
$ 100.00
4%
$
D’Angelo’s/Papa Gino’s
$ 10.00
8%
$
Target
$ 25.00
2%
$
Dave & Busters
$ 25.00
13%
$
Target
$ 50.00
2%
$
Denny’s
$ 10.00
7%
$
Target
$ 100.00
2%
$
Domino’s
$ 10.00
8%
$
Wal-Mart
$ 25.00
2%
$
Dunkin Donuts
$ 10.00
4%
$
Wal-Mart
$ 100.00
2%
$
Hard Rock Café
$ 25.00
10%
$
Tanger Outlets (Westbrook)
$ 25.00
8%
$
IHOP
$ 25.00
8%
$
KFC
$ 5.00
9%
$
Longhorn Steakhouse
$ 25.00
9%
$
Ninety-Nine Restaurant
$ 25.00
13%
$
Olive Garden
$ 25.00
9%
$
Outback
$ 25.00
8%
$
Panera Bread
$ 10.00
9%
$
PF Chang
$ 25.00
9%
$
Pizza Hut
$ 10.00
8%
$
Quizno’s
$ 10.00
10%
$
Red Lobster
$ 25.00
9%
$
Restaurant.com – $50 value
$ 20.00
50%
$
Ruby Tuesday’s
$ 25.00
8%
$
Starbucks
$ 10.00
7%
$
Starbucks
$ 25.00
7%
$
Subway
$ 10.00
3%
$
TGI Friday’s
$ 25.00
9%
$
Wendy’s
$ 10.00
4%
$
Travel
Avis Car Rental
Best Western
Electronics/Gifts/Other
Advance Auto
$ 25.00
7%
$
Babies R Us
$ 20.00
1.5%
$
Barnes & Noble/B. Dalton
$ 10.00
9%
$
Barnes & Noble/B. Dalton
$ 25.00
9%
$
Bath & Body Works
$ 10.00
13%
$
Bath & Body Works
$ 25.00
13%
$
Bed, Bath & Beyond
$ 25.00
7%
$
Best Buy
$ 25.00
3%
$
Best Buy
$ 100.00
3%
$
Build-A-Bear Workshop
$ 25.00
8%
$
Cabela’s Card
$ 25.00
11%
$
Claire’s
$ 10.00
9%
$
Dick’s Sporting Goods
$ 25.00
5%
$
Hallmark
$ 25.00
4%
$
Jo-Ann Fabrics
$ 20.00
6%
$
Michael’s
$ 25.00
4%
$
Oriental Trading Company
$25.00
9%
$
RadioShack
$ 25.00
4%
$
$50
8%
$
Sports Authority
$ 25.00
8%
$
$25.00
12%
$
Staples
$ 25.00
5%
$
$ 25.00
4%
$
Carnival Cruises
$100.00
8%
$
Petsmart
Celebrity Cruises
$100.00
9%
$
Toys R Us/Babies R Us
$ 20.00
1.5%
$
Comfort Inn (Clarion/Quality)
$100.00
4%
$
Yankee Candle
$25.00
8%
$
Disney
$ 25.00
2%
$
Hyatt Hotels
$50.00
9%
$
Marriott
$50.00
8%
$
Sleep Inn
$100.00
4%
$
Hey, can you get this card
I saw on the website?__________________________________________
SCRIP Gift Certificate(s)
Entertainment
AMC Theaters
$ 25.00
7%
$
EB Games/GameStop
$ 25.00
4%
$
Regal Cinema (eg. Waterford)
$
$ 25.00
8%
Regal Cinema, Single Ticket
$ 9.50
16%
$
Six Flags One Day Admission
$35.00
8%
$
SpaFinder
$ 25.00
8%
$
Need a Gift Certificate for someone to pick out his or her own card? Fill out below!
To:
From:
$
Scrip cards are also available for the following upon request: AT&T 125 Min Prepaid; Baskin Robbins; Bonanza/Bennigans; Brueggers Bagels; Circuit City; Container
Store; Finish Line; HEB Grocery; Kay Jewelry; Motherhood; Office Depot; Office Max; Pizzeria Uno; Sally Beauty Supply; Sam’s Club; Sweet Tomatoes; Winn-Dixie,
and more! For a full listing of what we can acquire, see order.scrippro.com/vendors and www.glscrip.com/shop, then make a special request in the space above!