S.E. S. SCRIP ORDER FORM

Name ______Date______Phone #______

Method of Delivery: I will pick up / student will pick up / mail (circle)

Payment Method: Cash ______/ Check # ______Amount ______

Apply to : ______Tuition Account in the name of ______General Operating Budget

Company % $$$ # Amount Company % $$$ # Amount Big B's Supermarket 5% $10 Home Depot 3 $25 Individual Purchases only $25 $100 $50 $500 $100 Lowe's 4 $25 Sagona's Hardware 5% $50 $100 New Purchases Only $100 $500 Graugnard, Inc. 3% $1,000 Total Purchase Amount CVS Pharmacy 6 $25 6 $100 Merle Norman Cosmetics & Rite Aid 4 $25 Fleur de Lis Giftshop 3 $15 Walgreens 6 $25 $25 $100 $50 Entertainment AMC Theaters 8 $25 Winn Dixie 4 $25 Cinemark 4 $25 $100 United Artists/Regal Ent. 8 $25 Whole Foods 3 $25 iTunes 5 $15 $100 $25 Game Stop 3 $25 Disney 2% $25 $100 Wal-Mart/Sam's 2.5 $25 $1,000 $100 Restraurants $250 Applebees's 8 $25 Target 2 $25 Chili's/Macaroni Grill 11 $25 $100 Chuck E. Cheese's 8 $10 Auto Zone 8 $25 Cracker Barrel 9 $10 Advance Auto Parts 7 $25 Logan's Roadhouse 10 $25 Chevron 1 $50 Olive Garden/Red Lobster 9 $25 $100 Outback 8 $25 Exxon Mobil 1 $50 Papa John's Pizza 8 $10 Pizza Hut 8 $10 Texaco 1 $25 Ruth's Chris Steakhouse 10 $50 Shell 2.5 $25 Texas Roadhouse 8 $25 $50 Wendy's 4 $10 $100 Subway 6 $10 Ace Hardware 4 $25 Starbucks Coffee 7 $10 $100 $25 Ihop 8 $25 Company % $$$ # Amount Company % $$$ # Amount Retailers Amazon.com 3 $25 Pier 1 Imports 9 $25 3 $100 Radio Shack 4 $25 American Eagle Outfitters 10 $25 Ross Dress for Less 8 $25 Bass Pro Shops 9 $25 Stage 8 $25 Banana Republic 14 $25 Sally Beauty Supply 12 $25 Barnes Noble/B. Dalton 9 $10 Sears 4 $25 $25 $100 Bath & Body Works/ 13 $10 250 White Barn Candle Co. $25 Sephora 5 $20 Bed Bath & Beyond 7 $25 Shoe Carnival 5 $25 Best Buy 3 $25 Shutter Fly 9 $25 $100 Structure (Express) 13 $25 $250 Sunglass Hut 12 $25 Arepostale 7 $25 Talbot's 11 $25 Build a Bear Workshop 8 $25 ToysRUs/Babies/Kids 3 $20 Border's/Waldenbooks 8 $10 Williams-Sonoma/Pottery Barn 8 $25 $25 $100 Cabella's 11 $25 Gymboree 13 $25 $100 Nike 12 $25 The Children's Place 12 $25 Tanger Outlet Center 8 $25 Claire's 9 $10 Ulta 4 $25 Dillards 9 $100 Dick's Sporting Goods 8 $25 $25 8 $100 Hallmark 4 $25 Zappos.com 8 $25 Kohl's Department Store 4 $25 Overstock.com 8 $25 $100 PetSmart 4 $25 Dress Barn 8 $25 Regis Salons 8 $25 Express/Express for Men 10 $25 Crazy 8 13 $25 Foot Action 9 $25 T.J. Maxx/Marshalls/HG 7 $25 Finish Line 10 $25 $100 Foot Locker/Champs/Foot Act 9 $25 DSW 9 $25 Famous Footware 8 $25 Buckle 8 $25 Gap/Kids/Baby/Old Navy 14 $25 GNC 8 $25 JC Penny's 5 $100 $25 K Mart/Super K Mart 4 $25 Lands End 16 $25 Lane Bryant 6 $25

Macy's 10 $100 $25 Marshalls/TJ Maxx 7 $100 $25 Motherhood Maternity 6 $25 Mimi Maternity 6 $25 Pier 1 9 $25 Michaels 4 $25 Kay Jewlers 12 $25 Office Depot 4 $25 $100 Payless Shoes 13 $20 Total Page 2