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SCRIP Order Form Family: Order Date: Amount: RESTAURANTS PRODUCT REBATE QTY TOTAL PRODUCT REBATE QTY TOTAL 800 Degrees Pizza $25 10.0% Fazoli's $25 7.0% Applebee's $25, $50 8.0% Hall's Dining $15 10.0% Arby's $10 8.0% IHOP $25 8.0% Baker Street $50 9.0% Logan's Steakhouse $25 10.0% Blaze Pizza $25 10.0% McDonalds $10, $50 5.0% Bob Evans $10 10.0% Mocha Lounge $25 8.0% Buffalo Wild Wings $10, $25 8.0% Moe's Southwest Grill $25 10.0% Burger King $10 4.0% Noodles & Company $10 8.0% Casa Restaurant $10 5.0% O'Charley's $25 13.0% Cebolla's $20 9.1% Outback/Bonefish $25, $50 8.0% Chipotle Mexican Grill $10 10.0% Panera Bread $10, $25 8.0% Chop's Steaks & Seafood $25 10.0% Papa John's Pizza $10 8.0% Cold Stone Creamery $10 11.0% Pizza Hut $10 8.0% Cookie Cottage $10 10.0% Red Lobster $25 8.0% Cosmos $10 16.0% Red Robin $25 8.0% Culver's $10 10.0% Rise N Roll Bakery 5.0% Darden $25 8.0% Salsa Grille $10 10.0% (Olive Garden, Longhorns, Bahama Breeze, Cheddars) Shigs-N-Pit / Mad Anthony $25 10.0% Dairy Queen $10 3.0% Spyros $10 7.0% Debrands $10 10.0% Starbucks $10, $25 7.0% Dominos $10 8.0% Steak 'n Shake $10 8.0% Dunkin' Donuts $10, $25 2.5% SUBWAY Gift Card $10, $50 6.0% GAS / CAR Taco Bell $10 5.0% PRODUCT REBATE QTY TOTAL Tim Horton's $10 5.0% 76 Gas $25, $100 1.5% Wendy's $10 4.0% BP $100, $250 1.5% Ziano's $25 15.0% LASSUS $50 4.0% TRAVEL / ENTERTAINMENT Marathon $25, $100, $250 3.0% PRODUCT REBATE QTY TOTAL Meijer $100 3.0% AMC Theatres $25 8.0% Mike's Carwash $9 22.2% Budget car $50 8.0% Safeway $25, $100 4.0% Chucky Cheese $10 8.0% Shell $100 2.0% Crazy Pinz $30 16.0% Speedway $100 4.0% Delta Airlines $250, $1000 4.0% The Tube Carwash $9 20.0% Disney $25, $100 3.0% Walmart/Sam's $25,$100,$250 2.5% GameStop $25 3.0% Hilton Hotels $100, $500 2.0% Regal Cinemas $25 8.0% [email protected] RETAIL PRODUCT REBATE QTY TOTAL PRODUCT REBATE QTY TOTAL Amazon $25, $100 2.5% Lands' End $100 16.0% American Girl $25, $100 9.0% L.L. Bean $25, $100 16.0% Barnes & Noble $5, $10, $25 8.0% Lowe's $25, $100, $500, $1000 4.0% Bath & Body Works $10, $25 13.0% Macy's $25, $100 10.0% Bed, Bath & Beyond $25, $100 7.0% Marshalls/T.J.Maxx/Home Goods $25, 7.0% $100 Best Buy $25, $100, $250 4.0% Meijer $25, $50, $100 3.0% Connolly's Do It Best $25 20.0% Menards $25, $100, $500 3.0% CVS $25, $100 6.0% Michael's Crafts $25 4.0% Disney $25, $100, $1000 3.0% Nike $25 12.0% Dick's Sporting Goods $25, $100 8.0% Office Max / Office Depot $25 5.0% Fresh Thyme Market $50, $100 5.0% Payless Shoe Source $20 13.0% Foot Locker $25 8.0% Peerless Cleaners $20 5.0% Gap/BR/Old Navy $25, $100 14.0% PetSmart $25 5.0% GameStop $25 3.0% Pottery Barn $25, $100 8.0% Gordon Food Service (GFS) $25 4.0% Shoe Carnaval $25 5.0% Gymboree $25 13.0% Staples $25, $100 5.0% Hallmark $25 4.0% SteinMart $25 7.0% Hill's Meat Market $25 4.0% Target GiftCard $25, $100 2.5% Home Depot $25, $100, $500, $1000 4.0% Walgreens $25, $100 6.0% J. Crew $25 13.0% Walmart/Sam's Club $10, $25, $100, 2.5% $250 J.C. Penny $25 5.0% Zappos $25, $100 8.0% Jack Laurie Flooring $500 min. 5.0% Jo-Ann Fabrics $25 6.0% Kohls $25, $100 4.0% WRITE-INS : more options @ www.shopwithscrip.com Order filled by: Order Entered on: Order Entered by: ** SHADED RETAILERS ARE AVAILABLE AT THE SCRIP STORE ** [email protected].
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