LCS Family Order Form To view the full list of over 300 participating retailers, visit shopwithscrip.com or email [email protected]. Name Order Date Check # Order Total: $ Local Product % QTY Total Frost Me Sweet $25.00 8% $ Porter's Real BBQ $20.00 10% $ Product % QTY Total Product % QTY Total 76 Gas $100.00 1.5% $ Comfort Inn $100.00 4% $ Ace Hardware $100.00 4% $ Crate and Barrel $100.00 8% $ Albertsons $100.00 4% $ Crazy 8 $25.00 13% $ Albertsons $25.00 4% $ Dairy Queen $10.00 3% $ Amazon.com $100.00 2.5% $ Del Taco $10.00 7% $ Amazon.com $25.00 2.5% $ Dell Computer $100.00 4% $ American Eagle Outfitters $25.00 10% $ Delta Air Lines $250.00 4% $ Applebee's® $25.00 8% $ Denny's $10.00 7% $ Applebee's® $50.00 8% $ Discover® Universal Gift Card $100.00 1.25% $ Arby's $10.00 8% $ Discover® Universal Gift Card $50.00 1.25% $ ARCO $100.00 1.5% $ Disney $100.00 2% $ AutoZone $25.00 8% $ Domino's $10.00 8% $ Avis Car Rental $50.00 8% $ Econo Lodge $100.00 4% $ Baja Fresh $25.00 7% $ Express $25.00 10% $ Banana Republic $100.00 14% $ Exxon $250.00 1% $ Barnes & Noble $100.00 9% $ Exxon $50.00 1% $ Barnes & Noble $25.00 9% $ Famous Footwear $25.00 8% $ Bass Pro Shops $100.00 9% $ Foot Locker $25.00 9% $ Bath & Body Works $25.00 13% $ Footaction USA $25.00 9% $ Bed Bath & Beyond $100.00 7% $ GameStop $25.00 3% $ Bed Bath & Beyond $25.00 7% $ Gap $100.00 14% $ Best Buy® $100.00 4% $ Gap $25.00 14% $ Best Buy® $25.00 4% $ GNC $25.00 8% $ Best Buy® $250.00 4% $ Great Clips $25.00 8% $ Best Western International $100.00 12% $ Great Harvest Bread $10.00 6% $ Big 5 Sporting Goods $25.00 8% $ Groupon.com $25.00 7% $ Bonefish Grill $25.00 8% $ Gymboree $25.00 13% $ Bonefish Grill $50.00 8% $ Hallmark $25.00 4% $ Buckle $25.00 8% $ HomeGoods $25.00 7% $ Budget Car Rental $50.00 8% $ Icing $10.00 9% $ Buffalo Wild Wings $25.00 8% $ IHOP $25.00 8% $ Burger King $10.00 4% $ iTunes® $15.00 5% $ Burlington Coat Factory $25.00 8% $ iTunes® $25.00 5% $ Carl's Jr. $10.00 5% $ J. Crew $25.00 13% $ Carter's $25.00 10% $ Jack in the Box $10.00 4% $ Champs Sports $25.00 9% $ jcpenney $100.00 5% $ Cheesecake Factory $25.00 5% $ jcpenney $25.00 5% $ Chevron $100.00 1.5% $ Jiffy Lube $30.00 8% $ Chevron $250.00 1.5% $ Jo-Ann Fabric & Craft Stores $25.00 6% $ Children's Place $25.00 12% $ Journeys $25.00 10% $ Chipotle Mexican Grill $10.00 10% $ Journeys Kidz $25.00 10% $ Circle K $100.00 1.5% $ Kids Foot Locker $25.00 9% $ Claire's $10.00 9% $ Kohl's $100.00 4% $ Product % QTY Total Product % QTY Total Krispy Kreme Doughnuts® $10.00 8% $ Ruth's Chris Steak House $50.00 10% $ L.L.Bean $25.00 16% $ Safeway $100.00 4% $ Lady Foot Locker $25.00 9% $ Safeway $25.00 4% $ Lane Bryant $25.00 8% $ Sally Beauty Supply $25.00 12% $ Little Caesar's Pizza $20.00 8% $ Sears $100.00 4% $ Lowe's $100.00 4% $ Sears $25.00 4% $ Lowe's $1000.00 4% $ Sears $250.00 4% $ Lowe's $25.00 4% $ Sears Auto Service Center $100.00 4% $ Macy's $100.00 10% $ See's Candies $25.00 9% $ Macy's $25.00 10% $ Sephora $20.00 5% $ Marshalls $100.00 7% $ Shell $100.00 2% $ Marshalls $25.00 7% $ Shell $25.00 2% $ Maurices $20.00 7% $ Shell $50.00 2% $ Men's Wearhouse $25.00 8% $ Shopko $100.00 3% $ Michaels $25.00 4% $ Shopko $25.00 3% $ Mobil $250.00 1% $ Shutterfly $25.00 9% $ Mobil $50.00 1% $ Staples $100.00 5% $ NOOK by Barnes & Noble $10.00 9% $ Staples $25.00 5% $ NOOK by Barnes & Noble $25.00 9% $ Starbucks $10.00 7% $ Nordstrom $100.00 6% $ Starbucks $25.00 7% $ Nordstrom Rack $100.00 6% $ SUBWAY® Restaurants $10.00 6% $ Office Depot / Office Max $100.00 5% $ SUBWAY® Restaurants $50.00 6% $ Office Depot / Office Max $25.00 5% $ Supercuts $25.00 8% $ Old Navy $100.00 14% $ Target $25.00 2.5% $ Old Navy $25.00 14% $ Target $50.00 2.5% $ Olive Garden ® $25.00 9% $ Texaco $100.00 1.5% $ OshKosh $25.00 10% $ Texaco $50.00 1.5% $ Outback Steakhouse $25.00 8% $ Texas Roadhouse $25.00 8% $ Outback Steakhouse $50.00 8% $ The Home Depot $100.00 4% $ Overstock.com $25.00 8% $ The Home Depot $1000.00 4% $ P.F. Chang's China Bistro $25.00 8% $ The Home Depot $25.00 4% $ Panda Express $25.00 8% $ The Home Depot $500.00 4% $ Panera Bread $10.00 9% $ T.J. Maxx/Marshalls/HomeGoods $100.00 7% $ Panera Bread $25.00 9% $ T.J. Maxx/Marshalls/HomeGoods $25.00 7% $ Papa John's Pizza $10.00 8% $ Taco Bell $10.00 5% $ Papa Murphy's Pizza $10.00 8% $ Target $100.00 2.5% $ Payless Shoes $20.00 13% $ Toys"R"Us $100.00 3% $ PetSmart $25.00 4% $ Toys"R"Us $20.00 3% $ Pier 1 Imports $25.00 9% $ ULTA $25.00 4% $ Pizza Hut (Not AK or HI) $10.00 8% $ Under Armour® $25.00 11% $ Princess Cruise Lines $100.00 6% $ Walgreens $100.00 6% $ Qdoba Mexican Grill $25.00 7% $ Walgreens $25.00 6% $ Quality Inn $100.00 4% $ Walmart $100.00 2.5% $ Red Lobster ® $25.00 9% $ Walmart $25.00 2.5% $ Red Robin $25.00 9% $ Walmart $250.00 2.5% $ Regal Theatres $25.00 8% $ Wendy's $10.00 4% $ REI $25.00 8% $ West Elm $100.00 8% $ Restaurant.com $20.00 50% $ Williams-Sonoma $100.00 8% $ Rite Aid $25.00 4% $ Pottery Barn $100.00 8% $ Royal Caribbean $500.00 13% $ Pottery Barn Kids $100.00 8% $