Family Order Form Platinum Booster Club Please note that these are NOT all the retailers available. Check out the Participating Retailers List.

Name Athlete's Name

Check # Order Date

Clothing & Accessories Department Store Product % QTY Total Product % QTY Total adidas $25.00 13% $ Dillard's $25.00 9% $ Aeropostale $25.00 10% $ jcpenney $25.00 5% $ American Eagle Outfitters $25.00 10% $ Kohl's $25.00 4% $ Famous Footwear $25.00 8% $ Macy's $25.00 10% $ Gap $25.00 14% $ Sears $25.00 4% $ Gymboree $25.00 13% $ Dining - Casual HomeGoods $25.00 7% $ Product % QTY Total Icing $10.00 9% $ Applebee's $25.00 8% $ Journeys $25.00 10% $ Buffalo Wild Wings $25.00 8% $ Journeys Kidz $25.00 10% $ Chili's Grill & Bar $25.00 11% $ Kids Foot Locker $25.00 9% $ Chuck E. Cheese $10.00 8% $ L.L.Bean $25.00 16% $ Cracker Barrel $25.00 9% $ Lands' End $25.00 16% $ $25.00 10% $ Limited $25.00 9% $ IHOP $25.00 8% $ Marshalls $25.00 7% $ Macaroni Grill $25.00 11% $ Old Navy $25.00 14% $ O'Charley's $25.00 13% $ Shoe Carnival $25.00 5% $ Old Country Buffet $25.00 5% $ T.J. Maxx $25.00 7% $ Olive Garden ® $25.00 9% $ T.J. Maxx/Marshalls/HomeGoods 7% $ $25.00 8% $ $25.00 $25.00 8% $

Total Due All Columns: Make Checks Payable To: The Seller's Name $ Dining - On The Go $25.00 9% $ Product % QTY Total Red Lobster ® $25.00 9% $ Arby's $10.00 8% $ $25.00 9% $ $10.00 4% $ Ruby Tuesday $25.00 8% $ $10.00 3% $ TGI Fridays $25.00 9% $ Domino's $10.00 8% $ Entertainment Dunkin' Donuts $25.00 3% $ Product % QTY Total Fazoli's $25.00 7% $ AMC Theatres $25.00 8% $ Hardee's $10.00 5% $ Barnes & Noble $25.00 9% $ Little Caesar's Pizza $20.00 8% $ Family Video $10.00 12% $ Long John Silver's $10.00 8% $ (, IL 9% $ Papa John's Pizza $10.00 8% $ NOOKonly) $100.00 by Barnes & Noble $25.00 9% $ St. Louis Bread Company $25.00 9% $ Gas & Auto $25.00 7% $ Product % QTY Total ® $10.00 6% $ BP $50.00 1.5% $ Bell $10.00 5% $ Circle K $25.00 1.5% $ Wendy's $10.00 4% $ Exxon $50.00 1% $ Discount Store Jiffy Lube $30.00 8% $ Product % QTY Total Shell $25.00 2.5% $ Kmart $25.00 4% $ Grocery Sam's Club $25.00 2.5% $ Product % QTY Total Target $25.00 2.5% $ Shop 'N Save (IL and MO only) $25.00 4% $ Walmart $25.00 2.5% $ Home Decor Electronics & Office Product % QTY Total Product % QTY Total Bed Bath & Beyond $25.00 7% $ Best Buy® $25.00 3% $ PBteen $25.00 8% $ EB Games $25.00 3% $ Pottery Barn $25.00 8% $ GameStop $25.00 3% $ Office Depot $25.00 5% $ Office Max $25.00 5% $

Total Due All Columns: Make Checks Payable To: The Seller's Name $ Home Improvement Sporting Goods Product % QTY Total Product % QTY Total Lowe's $25.00 4% $ Bass Pro Shops $25.00 9% $ Menards $25.00 3% $ Cabela's $25.00 11% $ The Home Depot $25.00 4% $ Dick's Sporting Goods $25.00 8% $ Online & Catalog Sports Authority $25.00 8% $ Product % QTY Total Travel Amazon.com $25.00 3% $ Product % QTY Total iTunes® $25.00 5% $ Carnival Cruise Lines $100.00 8% $ Overstock.com $25.00 8% $ Delta Air Lines $250.00 4% $ Service Disney $25.00 2% $ Product % QTY Total Famous Hair $25.00 8% $ Product Name Amount % QTY Total Specialty Retailer $ Product % QTY Total $ American Girl $25.00 9% $ $ Babies"R"Us $20.00 3% $ Bath & Body Works $25.00 13% $ Build-A-Bear Workshop $25.00 8% $ CVS/pharmacy $25.00 6% $ Harry & David $25.00 10% $ Honey Baked Ham $25.00 12% $ Jo-Ann Fabric and Craft Stores 6% $ $25.00Michaels $25.00 4% $ Oriental Trading Company $25.00 9% $ Sally Beauty Supply $25.00 12% $ Sephora $20.00 5% $ Total Amount of Gift Cards Toys"R"Us $20.00 3% $ Total Cost Walgreens $25.00 6% $

Total Due All Columns: Make Checks Payable To: The Seller's Name $