St. Pius X School Scrip Order Form (PAGE 1 OF 2) PLEASE SEE OTHER SIDE Orders must be placed by Monday at 3:00 pm to receive on Friday Revised August 2016 Student Name (oldest or only): Grade: Check # Order Date: Phone #: Email Address: PLEASE SEND SCRIP HOME PLEASE HOLD MY SCRIP ORDER. WITH MY CHILD I WILL PICK IT UP IN THE OFFICE Product/ Circle Quantity Product/ Circle Quantity Vendor Denomination Each TOTAL Vendor Denomination Each TOTAL Acapulco $25 Comfort Inn $100 Aeropostale $25 Crazy 8 $25 Albertsons $25 CVS Pharmacy $25 Albertsons $100 Denny's $10 Amazon.com $25 Dick's Sporting Goods $25 Amazon.com $100 Disney Gift Card $25 AMC Theaters $25 Disney Gift Card $100 American Eagle $25 Domino's Pizza $10 Applebee's $25 Edward's Theaters $25 Arco $50 El Camino $10 Auto Zone $25 El Camino $25 Baja Fresh $25 El Pollo Loco $10 Banana Republic $25 El Torito $25 Barnes & Noble $10 Express $25 Bath & Body Works $10 Exxon/Mobil $50 Bed Bath & Beyond $25 Foot Locker $25 Best Buy $25 Game Stop $25 Best Western $25 Gap $25 Best Western $100 GNC $25 Big 5 $25 Gymboree $25 Black Angus $25 Home Depot $25 Bucca DiBeppo $25 Home Depot $100 Buffalo Wild Wings $10 IHOP $25 Build A Bear $25 Islands $25 Burger King $10 iTunes $15 Burlington Coat Factory $25 iTunes $30 Chevron $50 Jack in the Box $10 Chili's $25 JCPenney $25 Chipotle $10 Jiffy Lube $30 Chuck E Cheese's $10 Jo-Ann Fabric & Craft $25 Claire's $10 Kohl's $25 Coffee Bean & Tea Leaf $25 Kohl's $100 Cold Stone $10 Little Caesar's $20 Comfort Inn $25 Lowe's $25 Subtotal Subtotal Subtotal (this page) $ Make Checks Payable to ST. PIUS X SCHOOL Product/ Circle Quantity Product/ Circle Quantity Vendor Denomination Each TOTAL Vendor Denomination Each TOTAL Lowes $100 Souplantation $25 Macaroni Grill $25 Sports Authority $25 Macy's $25 Staples $25 Marshalls $25 Starbucks $10 Michael's Craft Store $25 Stater Bros. $25 Mimi's Café $25 Stater Bros. $100 Nike $25 Subway $10 Office Depot $25 Taco Bell $10 Old Navy $25 Target $25 Olive Garden $25 Target $100 Outback Steakhouse $25 Texaco $50 P.F. Changs $25 TGIF $25 Papa John's $10 The Children's Place $25 Payless Shoes $20 TJMaxx $25 Pep Boys $20 Toys R Us $20 Pier 1 Imports $25 Under Armour $25 Pizza Hut $10 Vons $25 Rainforest Café $25 Walgreens $25 Red Lobster $25 Walmart/Sam's Club $25 Red Robin $25 Walmart/Sam's Club $100 Regal Theater $25 Wendy's $10 Rite Aid $25 X Box Live $20 Ross $25 Ruth Chris Steak House $50 Sears $25 Sears $100 See's Candies $19 Sephora $20 Shell $25 Shell $50 Shutterfly $25 Smart & Final $25 Smart & Final $100 Subtotal Subtotal Total from this page $ Make Checks Payable to ST. PIUS X SCHOOL Total from other side $ Please write student name & grade in memo area of your check *ALL SALES FINAL, NO EXCHANGES. Grand Total $ Thank you for your order & your support! Vendor participation is subject to change. (page 2 of 2).