Over for Payment Information Please

Vendor Total Vendor Total Due (% rebate) Denomination # of cards Due (% rebate) Denominati # of cards on 1-800-Flowers (8%) $50 Home Depot (4%) $25 $100 Amazon.com (3%) $25 iTunes (5%) $15 $100 $25 AMC Theatre (8%) $25 JC Penny (5%) $25 American Girl $25 Kohl’s(4%) $25 Store (9%) $100 Applebee’s (8%) $25 Little Caesars Pizza $20 (8%) Barnes & $10 Limited (9%) $25 Noble (9%) $25 Bath & Body $10 Lowes (4%) $25 Works (13%) $25 $100 Bass Pro Shop (9%) $25 Macy’s (10%) $25 $100 Bed Bath & Beyond (7%) $25 Maggiano’s (11%) $25 Best Buy (3%) $25 Noodles & Co (8%) $10 $100 Brio’s (12%) $25 Olive Garden (9%) $25 Build A $25 Oriental Trading $25 Bear (8%) Company (9%) Cabela’s (11%) $25 Panera (9%) $10 $25 California $25 PF Chang’s/Pei Wei $25 Pizza Kitchen (8%) (8%) Carter’s Baby & Kids $25 Qdoba (7%) $25 (10%) Cheesecake Factory (5%) $25 Red Robin (9%) $25 Children’s Place (12%) $25 REI (8%) $25 Chipotle Mexican Grill $10 Restoration $25 (10%) Hardware (12%) Crate and Barrel (8%) $25 Ruth Chris’s $50 Steakhouse (10%) CVS $25 Starbucks (7%) $10 Pharmacy (6%) $100 $25 Dave & Busters (13%) $25 Shutterfly (9%) $25 Dicks Sporting Goods $25 Subway (6%) $10 (8%) $100 Dierbergs (5%) $25 Target (2.5%) $25 $100 $100 Flemings (8%) $25 TGI Fridays (9%) $25 Game Stop (3%) $25 Toys R Us (3%) $20 Gap/Old Navy (14%) $25 Walgreens (6%) $25 Groupon (7%) $25 Walmart (2.5%) $25 $100 Gymboree (13%) $25 Harry & $25 David (10%)

Don’t see what you want? Check out www.shopwithscrip.com for the full list of available cards. Register yourself using the code 66C4F96371LL or return this form and we can place orders on your behalf. One time or recurring orders available. Orders received by the 20th of the month will be received by the 5th of the following month. (OVER FOR PAYMENT INFORMATION PLEASE) Multiple convenient ways to purchase gift cards from Temple Israel:  Set-up standing monthly order of for any of nearly 700 vendors.  Place a one-time order.  Place an order for one of nearly 700 different cards at www.shopwithscrip.com when you register your family using enrollment code 66C4F96371LL.  Purchase in stock gift cards for Dierbergs, Whole Foods, Panera, or many other gift cards from the Temple office or at various programs. Contact the office for availability.

To place a subscription or one time order, or to authorize ACH or Credit Card payments, mail this form to Scrip Coordinator Diane Packman, c/o Temple Israel, 1 Rabbi Alvan D. Rubin Dr., St. Louis, MO 63141.

□ I will pick up my cards at the Temple. (We will notify you via email when your order is ready.) □ Please send my cards home with my child. Child’s Name: ______Teacher’s Name: ______□ Please mail my cards via U.S. postal mail. (Monthly standing orders or one time orders of $100 or more are mailed at your direction during the first week of each month.)

□ Please enroll me in the monthly subscription for the following order. (Enter quantity of each card desired.) Dierbergs: __ $25 __$100 Whole Foods: __ $25 __$100 StL Bread Co: __$10 __ $25 Starbucks: __ $10 __ $25 CVS: __ $25 __ $100 Walgreens: __ $25 __ $100 Other: ______□ Please contact me regarding standing orders for other retailers.

□ Check enclosed (payable to Temple Israel) □ Please charge my ACH account on file □ Please charge my credit card on file. □ I authorize Temple Israel to draw an ACH auto debit for scrip purchases ($25 minimum, attach a voided check) □ I authorize Temple Israel to charge my credit card for scrip purchases (choose one): □ For one-time purchase ($18 minimum required) □ For all current and future scrip purchases (Credit cards are accepted for orders where the TI rebate is 5% or greater. Note: the Temple can only keep one credit card number on file per family.) Charge: □ MasterCard □ VISA □ Discover Acct. No. ______- ______- ______- ______Exp. __ __ / __ __ □ Please add a 3% tax deductible donation to credit card purchases to help cover credit card fees. Please complete information below: Name: ______Address: ______City: ______State ______Zip _____ Phone (__) ______E-mail: ______