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Copy of Scrip Family Order Form Family Order Form Office Use Only ST. NICHOLAS ACADEMY/LOUISVILLE, KY Order Date __________Order Total ____________ NAME Phone Method of payment ADDRESS Cell CITY STATE ZIP STUDENT NAME DELIVERY PREFERENCE Home Room Send With: I will pick up in the Office. Apparel & Accessories Electronics & Office Product %Qty TotalProduct % Qty Total American Eagle Outfitters $25 9% $Best Buy $25 2% $ Brooks Brothers $25 16% $BEST BUY $100 2% $ Claire's $10 9% $Best Buy $250 2% $ Dress Barn $25 8% $Circuit City $25 3% $ Eddie Bauer $25 14% $Circuit City $100 3% $ Express $25 13% $Game Stop $25 3% $ Finish Line $25 10% $Office Depot $25 4% $ Ft. Locker $25 9% $Office Max $25 5% $ Gap/Banana/Old Navy $25 9% $RadioShack $25 4% $ Gymboree $25 13% $Staples $25 Gift Card 5% $ J. Crew $25 13% $Staples $100 5% $ Lands' End $25 9% $ Entertainment Lands' End $100 9% $Barnes & Noble/B.Dalton $10 10% $ Limited $25 9% $Barnes & Noble/B.Dalton $25 10% $ Maurices $20 7% $Barnes &Noble "Teacher Gift" Card $20 10% $ Men's Wearhouse $25 8% $Blockbuster $10 7% $ Motherhood $25 6% $Blockbuster Night Card $12.00 15% $ Nine West $25 8% $Blockbuster Single Game $6 15% $ Payless Shoes $20 13% $Blockbuster Single Movie Rental $3.79 15% $ Shoe Carnival $25 5% $Borders/Waldenbooks $10 9% $ Talbots $25 11% $Borders/Waldenbooks $25 9% $ The Children's Place $25 12% $Cinemark Cinema $25 Card 4% $ TJ Maxx/Marshall's $25 7% $fye/Suncoast $25 6% $ TJ Maxx/Marshall's $100 7% $Showcase/Cinema de Lux $25 9% $ Department Store Gas & Auto Dillard's $25 9% $BP Gas Stations $50 3% $ Dillard's $100 9% $Chevron $50 2% $ JCPenney $25 6% $Chevron $100 2% $ JCPenney $100 6% $Exxon/Mobil $50 All States 3% $ Kohl's Dept. Store $25 4% $Marathon $25 3% $ Kohl's Dept. Store $100 4% $Marathon $100 3% $ Macy's/Federated $25 10% $Marathon $250 4% $ Macy's/Federated $100 10% $Pep Boys $20 4% $ Sears $25 Gift Card 4% $Shell $25 3% $ Sears $100 GIFT Card 4% $SHELL $100 3% $ Sears $250 Card 4% $Speedway/SuperAmerica $25 4% $ Home Decor Speedway/SuperAmerica $100 4% $ Bed Bath & Beyond $25 7% $Sunoco $50 2% $ Linens 'N Things $25 10% $Texaco $25 2% $ Pier 1 $25 9% $ Discount Store Pottery Barn/Williams Sonoma $25 8% $Kmart $25 4% $ Pottery Barn/Williams Sonoma $100 8% $Kmart $50 4% $ Service Value City $10 9% $ Regis Salons $25 8% $ Dining - Casual Home Improvement Applebee's $25 8% $Ace Hardware $25 4% $ Bob Evans $10 Card 10% $Home Depot $25 3% $ Buca di Beppo $25 8% $Home Depot $100 3% $ California Pizza Kitchen $10 4% $Home Depot $500 3% $ Champps Restaurant $25 5% $Lowe's $25 Gift Card 4% $ Cheesecake Factory $25 5% $LOWE'S $100 Gift Card 4% $ Chili's $25 11% $LOWE'S $500 Gift Card 4% $ Chuck E Cheese $10 8% $ Online & Mail Order Cracker Barrel $10 9% $1800Flowers $25 10% $ Damon's $25 9% $Amazon.com $25 4% $ Dave & Buster's $25 13% $iTunes $15 4% $ Denny's $10 7% $LL Bean $25 17% $ Don Pablos $25 Gift Card 8% $LL Bean $100 Card 17% $ Golden Corral $25 3% $Shutterfly $25 card 14% $ Hard Rock Café $25 8% $Ticketmaster $50 4% $ Logan's Roadhouse $25 8% $TravelocityIncentives.com $100 9% $ Longhorn Steakhouse $25 11% $ Specialty Retailer Max & Erma's $20 13% $Bath & Body Works $10 18% $ O'Charley's $25 Card 13% $Bath & Body Works $25 18% $ Outback/Carrabas $25 Card 5% $Brookstone $25 12% $ Red Lobster/Olive Garden $25 9% $Build-A Bear Workshop $25 8% $ Ruby Tuesday's $25 8% $CVS Pharmacy $25 2% $ Ryan's $5 7% $GNC $25 8% $ Texas Roadhouse $25 8% $Hickory Farms $10 15% $ TGI Fridays $25 10% $Honey Baked Ham $10 12% $ Uno Chicago Grill $25 17% $Kay Jewelry $25 12% $ Dining - Fine KB Toys $20 9% $ Landry's Seafood $25 9% $Rite Aid $25 4% $ Ruth's Chris $50 10% $Sally Beauty $25 12% $ Dining - On The Go Sunglass Hut $25 12% $ Arby's $10 Gift Card 8% $Toys R Us/Babies R Us $20 2% $ Burger King $10 4% $Walgreens $20 2% $ Cold Stone Creamery $10 8% $Walgreens $100 2% $ Domino's $5 5% $ Sporting Goods Domino's $14 Pizza & 2-liter 28% $Bass Pro Shops $25 11% $ Dunkin Donuts $10 4% $Cabela's $25 Card 14% $ Fazoli's $25 7% $Cabela's $100 Card 14% $ Great Harvest Bread $10 8% $Dick's Sporting Goods $25 5% $ KFC $5 9% $ Utility Long John Silver $5 9% $675Min Total Access Phone Card $20 17% $ Panera Bread $10 9% $AT&T 100+ Prepaid Card $9.50 20% $ Papa John's $10 8% $ Xtra Stuff Pizza Hut $10 9% $Gift Card HOLIDAY Wrapper 16pk $5.60 20% $ Qdoba $25 7% $Gift Card Wrapper-16 Pack $5.60 20% $ Starbucks $10 7% $Scrip Wallet $1 15% $ Starbucks $25 7% $ TOTAL ORDER AMOUNT: Subway $10 3% $ Subway $50 3% $ CHECK #:___________AMOUNT:____________ Wendy's Card $10 4% $ CASH:______________ Grocery Gordon Foods Serv Marketplace $25 4% $ UPDATED NOVEMBER 13, 2007 Gordon Foods Serv Marketplace $100 4% $ Travel Product %Qty Total American Airlines $50 8% $ American Airlines $100 8% $ American Airlines $250 8% $ Avis Car Rental $50 8% $ BedandBreakfast.com $50 10% $ Best Western Int'l $25 12% $ Best Western Int'l $100 12% $ Budget Car Rental $50 8% $ Carnival Cruise $100 8% $ Comfort Inn (Clarion,Quality,Sleep) $25 6% $ Comfort Inn (Clarion,Quality,Sleep) $100 6% $ Disney $25 2% $ Disney $100 2% $ Disney $1000 2% $ Hyatt Hotels $25 9% $ Hyatt Hotels $100 9% $ Marriott $50 Card 12% $ MARRIOTT $100 Card 12% $.
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