SCRIP ORDER FORM



Child’s FIRST Name________________________________ Grade__________ Date___________________________ Child’s LAST Name__________________________________ Cell Phone _________________________________________

ALL ORDERS WIL BE SENT HOME WITH YOUR OLDEST CHILD UNLESS OTHERWISE SPECIFIED



MERCHANTS

%

QUANTITY DENOMINATIONS

Amazon.com Barnes and Noble Barnes and Noble Cold Stone Creamery California Pizza Kitchen Chevron Cheesecake Factory Chipotle Mexican Grill CVS Home Depot Home Depot iTunes iTunes Lucky/SaveMart Lunardi’s Macy’s Michael’s Noah’s Bagels Nob Hill Foods/Raleys Panera Bread Peet’s Coffee Safeway Safeway See’s Candies Shell Sprouts Starbuck’s Starbuck’s Target Target ToysRUs Whole Foods Whole Foods

3% 9% 9% 8% 6% 1% 6% 10% 6% 3.5% 3.5% 6% 6% 2% 5% 11% 4% 10% 4% 9% 8% 4% 4% 20% 2% 2.5% 6% 6% 2% 2% 1.5% 3% 3%







For office use only: Name _______________________ Date _______________________ Filled Yes____________________ Comments____________________ Paid Check #______ Cash_______

As of 9/9/2015





TOTAL

FOR OFFICE USE ONLY STATUS STATUS INITIALS FILLED UNFILLED

___________ x $100 $ ___________ x $10 $ ___________ x $25 $ ___________ x $10 $ ___________ x $25 $ ___________ x $50 $ ___________ x $25 $ ___________ x $10 $ ___________ x $25 $ ___________ x $25 $ ___________ x $100 $ ___________ x $15 $ ___________ x $25 $ ___________ x $25 $ ___________ x $50 $ ___________ x $25 $ ___________ x $25 $ ___________ x $10 $ ___________ x $100 $ ___________ x $10 $ ___________ x $20 $ ___________ x $25 $ ___________ x $100 $ ___________ x $16.50 $ ___________ x $50 $ ___________ x $25 $ ___________ x $10 $ ___________ x $25 $ ___________ x $25 $ ___________ x $100 $ ___________ x $20 $ ___________ x $25 $ ___________ x $100 $ Subtotal: Page 1 - $__________________ Subtotal: Page 2 - $__________________ TOTAL $______________________





(checks payable to St. Mary School)







SPECIAL ORDERS (allow one week for delivery) Order MERCHANT Ace Hardware Amazon.com American Eagel Applebee's ARCO Athleta Babies"R"Us Baja Fresh Banana Republic Bath & Body Works Bed Bath & Beyond Best Buy Big 5 Bloomingdale's Buca di Beppo Build-A-Bear Carl's Jr. Chuck E. Cheese Claire's Container Store Crate and Barrel Disney Flemings Foot Locker GameStop Gap GNC Gymboree Honey Baked Ham Horchow J. Crew jcpenney Jo-Ann Fabric KFC Kmart Kohl's Lands' End

QTY Denom $25 $25 $25 $25 $50 $25 $20 $25 $25 $25 $25 $25 $25 $100 $25 $25 $10 $10 $10 $25 $25 $100 $25 $25 $25 $25 $25 $25 $25 $50 $25 $25 $25 $5 $25 $25 $25

TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Status

Order MERCHANT QTY Limited Lowe's Lucky Supermarket Marshalls Men's Wearhouse Mimi's Neiman Marcus Nike Nordstrom Nordstrom Office Depot Office Max Old Navy Olive Garden Outback Steakhouse P.F. Chang's PetSmart Pier 1 Imports Pottery Barn REI Rite Aid Ross Dress for Less Ruth's Chris Steak Sam's Club Sears Sephora Shutterfly Smart and Final Staples Subway T.J.Maxx Talbots Walgreens West Elm Williams Sonoma Zappos Zappos

Denom $25 $100 $25 $25 $25 $25 $50 $25 $25 $100 $25 $25 $25 $25 $25 $25 $25 $25 $25 $25 $25 $25 $50 $100 $100 $20 $25 $100 $25 $10 $25 $25 $25 $25 $25 $25 $100

TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Status

SPECIAL ORDER SUBTOTAL - PAGE 2 $_______________ (Transfer this total to Page 1)

Rev. 3/2/16

Page 2