Scrip Order Form

FAMILY NAME   CHECK #  
TELEPHONE NUMBER   CASH AMOUNT  
RETAILERS (%) Price QTY Total
Price
RETAILERS (%) Price QTY Total
Price
Ace Hardware (4%) $25     Lowe's (4%) $25     1
Albertsons (4%) $25     $100     2
Applebee's (8%) $25     Macy's (10%) $25     3
Barnes & Noble/B. Dalton (9%) $10     Mary Kay Cosmetics-Liz Pinchera (15%) $25     4
$25     Mimi's Cafe (8%) $25     5
Bath and Body Works (13%) $10     Outback/Carrabas (5%) $25     6
$25     Panera Bread (9%) $10     7
Bed Bath and Beyond (7%) $25     Papa John's (6%) $10     8
Best Buy (3%) $25     Payless Shoes (13%) $20     9
Blockbuster (7%) $10     Pizza Hut (9%) $10     10
Blockbuster Single Movie (15%) $3.79     Pier 1 (9%) $25     11
Bob Evans (10%) $10     Premier Oaks Movie Tickets (11%) $6.75     12
Boston Market (12%) $10     Publix (3%) $25     13
BP Gas Stations (2%) $50     $50     14
Burger King (4%) $10     $100     15
Chili's (11%) $25     $250     16
Claire's (9%) $10     $500     17
Cold Stone Creamery (8%) $10     Red Lobster/Olive Garden/Longhorn (9%) $25     18
Cracker Barrel (9%) $10     RJ Gators (10%) $25     19
CVS Pharmacy (6%) $25     Ross Dress for Less (8%) $25     20
Denny's (9%) $10     Sally Beauty (12%) $25     21
Dillard's (9%) $25     Sears (4%) $25     22
Disney (2%) $25     Sport's Authority (8%) $25     23
$100     Staples (5%) $25     24
Domino's (5%) $5     Starbuck's (7%) $10     25
Dunkin Donuts (4%) $10     $25     26
Game Stop (3%) $25     Steak & Shake (7%) $10     27
Gap/Banana/Old Navy (9%) $25     Subway (3%) $10     28
Hallmark (Johnstons) (10%) $10     Texas Roadhouse (8%) $25     29
Home Depot (4%) $25     TGI Fridays (9%) $25     30
$100     T.J. Maxx/Marshall's (7%) $25     31
iTunes (4%) $15     Toys R Us (2%) $20     32
JCPenny (5%) $25     Twisty Cone (20%) $5     33
Jo Ann Fabrics (6%) $20     Uno's (12%) $25     34
KFC (9%) $5     Walmart (2%) $25     35
Kohl's Dept. Store (4%) $25     $100     36
Krispy Kreme (50%) $6     $250     37
Michael's (4%) $25     Walgreen's (6%) $25     38
ACS Ribbon Gift Card (30%) $25     Wendy's (4%) $10     39
20090302rev7 Updated 3/3/09 TOTAL $