Name:______Personal Gift Card Order Form Date:______Phone:______SPECIALTY STORES Total Scrip Service Center - Revised 12-1-14 Email:______ACE Hardware* 4% $25 GROCERY Total AUTOMOTIVE Total RESTAURANTS Cont. Total $25 Amazon.com * For online 4% purchases. $50 Eco Car Wash* 26% $6 Olive Garden//Yard House * 8% $10 $100 Albertson’s & Sav On * 4% $100 Jiffy Lube 15% $30 Oswego Grill * 8% $25 Backyard Bird Shop * 8% $25 $10 Kaady Car Wash * 26% $6 * 8% $25 Barnes & Noble B Dalton * 8% $10 $20 14% $40 8% $15 7% $10 4% Oil Can Henry’s* * Bath & Body Works * Fred Meyer / QFC * $25 Washman Auto Spa 26% $4 & Cafe* 8% $10 Best Buy * 2% $50 $50 RESTAURANTS Papa John’s Pizza OR & SW WA 10% $5 Big 5 Sporting Goods * 8% $25 $100 Applebee’s * 8% $10 Papa Murphy’s Pizza* 8% $10 Build A Bear Workshop* 8% $25 Haggen / Top Foods * 7% $50 * 8% $10 Pastini Pastaria* 8% $20 Coastal Farm & Ranch * 4% $25 Lamb’s Markets* $50 4% $20 8% $10 8% $5 4% Bellagio’s Pizza * Pizza Caboose * Strohecker’s Market $100 Big Town Hero 8% $5 Pizzicato Gourmet Pizza Craft Warehouse * 8% $10 $50 Blitz Sports Pub * 99W, Ladd & Pearl 8% $10 Not airport, Bend, or Hood River 8% $10 Home Depot * 2% $50 New Seasons * 4% $100 Buffalo Wild Wings* 8% $25 No change back. iTunes * Internet music & more 3% $25 $25 * 4% $5 Pizza Schmizza OR & SW WA 10% $5 * 7% $5 Safeway * 4% $50 * 8% $10 * 7% $10 Joann Fabrics * 5% $25 $100 Carl’s Jr. / Green Burrito * 5% $10 Roundtable Pizza - Pdx metro area only 12% $10 1 dozen glazed 45% $9 Thriftway* Only for OR and SW WA. 4% $25 Chevy’s * 8% $15 Ruby Tuesday* 8% $10 Learning Palace * 8% $10 Whole Foods Market* R 3% $50 Chipotle * 9% $10 Shari’s Restaurant* 8% $20 Lowe’s * 4% $50 RETAIL / DEPARTMENT Davidson’s - Tigard - No change 8% $10 Sonic Drive-In* 8% $10 Michaels Crafts * 3% $25 Bed, Bath, & Beyond * 5% $10 Denny’s Restaurant * 5% $10 Stanford’s / Newport Bay/ Manzana* Peet’s Coffee * Use Fred Meyer 8% $20 Henry’s Tavern, Portland City Grill,Palomino, Bridgeport Village * Domino’s Pizza OR and WA only 12% $10 8% $25 cards at all FM Peet's Billy Heartbeats, Newport Seafood Grill,Kincaids All stores, restaurants, theater, kiosks - 4% $25 Elmer’s Pancake House 8% $5 Petco * 8% $25 not Croc Store.Tips deducted, then rebated. Famous Daves BBQ * 10% $25 $15 Pier 1 Imports * 8% $25 * 6% Cabela's * 8% $25 Figaro’s Pizza 12% $10 $100 Pottery Barn-Willams Sonoma* 7% $25

Retail Godfather’s Pizza Med Specailty/Lrg 2 top 27% $14 Sweet Tomatoes * 8% $25 Powell’s Books * 8% $10 Columbia Sportswear* 12% $50 outlets, employee stores for those w/access. HoneyBaked Ham * 8% $10 * 4% $10 See’s Candy -1lb. Certif. $18 value 7% $16 Dicks Sporting Goods * 8% $25 Izzy’s Pizza * 8% $20 Taco Time * OR and SW Wash. 10% $15 Staples Office Supplies* 4% $25 John’s Incredible Pizza Co * 8% $25 Tom’s Pancake House No Change back 8% $10 $5 GAP * Old Navy Banana Republic 12% $25 GAP KIDS ~ Outlet Stores One Card for All Kentucky Fried Chicken 7% $10 Veggie Grill * 9% $15 Coffee * 6% $10

JC Penney * 4% $25 Landry’s Restaurants *One card for ENTERTAINMENT $25 ClaimJumper, Morton’s Steak, Heathman Kohl’s * Payment on account in store. 4% $25 Cinemark - Century Theaters 7% $9 Tully’s Coffee * 10% $10 Restaurant Jake’s Grill @ Gov. Hotel, M & S 8% $25 Family Fun Center & Bullwinkles * Macy’s * 10% $25 Grill, Jake’sSeafood,Harborside,Chart Chinook Book 50% $20 Games,cars,golf,arcades, food/ Wilsonville Only 15% $25 House, McCormick’s & Schnmick’s Marshall’s-TJ Maxx/HomeGoods* 6% $25 Chinook App-Android or iPhone 50% $15 Nike, Inc. * Nike Town, Online, Outlets, McGrath’s Fish House * 7% $10 Family Theaters Tigard and Oak Grove 16% $10 12% $50 Employee store for those with access McMenamins / Ruby’s Spa * Regal Cinemas Gift Card * 7% $15 TOTAL all columns =

Payless Shoe Source* 12% $25 For any Restaurant, Brew Pub,Spa, 12% $25 Regal Cinemas Paper Ticket Please make check payable to: $ Hotel,Theater, Gift Shop, Hair Salon Adult prime time paper movie ticket is less than 7% $9.50 R.E.I. * All Stores and Online 8% $25 door price ______Ross Dress for Less* 8% $25 Old Spaghetti Factory No change back 8% $10 Thank You for your support * Indicates Gift Card No card return - order carefully Sears- Kmart-Lands End* 4% $50 Revised 12/1/14 For retail, online, outlets, automotive Call number on back or check store website for balance Target * 2.5% $25 The Children’s Place* 12% $25