IMMACULATE CONCEPTION SCHOOL SCRIP FUNDRAISING ORDER FORM Date: ____________________________ Please consider placing your order online. It's easy & convenient. Just go to shopwithscrip.com. You will need the Name: ___________________________ enrollment code L95E9C474418 to create an account. You may pick it up at the school or at Family receiving any weekend mass. If you are paying by scrip credit:_______________________ check, be sure to forward your payment to the school after (To help a family in need of tuition assistance, placing your order -or- pay with PrestoPay. write 'family in need'. Tuition credit may be Call Angie Ruzicka 641-330-6518 with any questions. split among several families.) Phone #: _________________________ If your order was not able to be completely filled, where would you like to pick up your order after it is complete: (circle one) ****Make checks payable to IC Scrip***** After Mass Send Home With My Child School Office Arnold Motors Notes: We will NOT accept returns or exchanges. Please order only what you will use! We will NOT hold checks. Gift cards need to be replaced immediately after sold in order to keep a full inventory. Local 'PENNIES FROM HEAVEN' Scrip Dollars May be used at the following local merchants: 218 Fuel Express/Ricks Wagon Wheel, Floyd Artwear Hair Creations by Brandi Auto Crafters Heaven's Best Carpet Cleaning Bayou Bend Mini Golf & Batting Cages Houdek Flooring Birdie and Bo's I Don't Care Blush Salon Spa Jendro Sanitation Cals Auto Repair, Inc McDonalds Carole & Co. North Iowa Coins Local Scrip Order: Cedar River Tanning Salon Nelson Tire & Auto Qty. $ Amt. Comet Bowl Ottos Oasis $1 Country Chiropractic-Dr. Lucas Pogemiller Pizza Ranch $5 Dairy Queen Pub on the Cedar $10 Darbe & Co. Boutique Quality Auto Service $20 Dave's Restaurant Rustic Corner $50 Dean Jewelers Saxony (not for use on clearance) $100 Derailed Bar & Spirits Schiller Fine Photography & Framing Total local: $ Dugan's Restaurant, Lounge & Catering Subway Express Lube Taco Johns Field Brothers Moving (Max $1,000) Theisen's Order Totals: Fingers & Toes Up2Date Fashions Local Scrip: $ Furniture Barn Wayne's Ski & Cyle above total Guthart Gallery & Framing Nat'l Scrip: $ total from back Rebate amounts listed are % from each purchase that each business has decided to donate to our Total Order: $ program. Since it is difficult to track where each local dollar is spent, the rebate given is an average. Currently the local rebate is 4%. This is periodically evaluated and subject to change. THE FOLLOWING TO BE COMPLETED BY PERSON AUTHORIZED TO FILL SCRIP ORDERS Order filled by: ___________________ Payment method: Cash / Check #_____ Please only highlight items on the back that were not able to be filled. They will be ordered and delivered according to the delivery method chosen at the top of this form. Was this order completely filled? Yes No Revised 5/14/18 Business/Value Rebate Qty Total Business/Value Rebate Qty Total Ace Hardware $25 4% $ Maurices $20 7% $ Ace Hardware $100 4% $ McDonald's $10 5% $ Amazon.com $25 2.5% $ McDonald's $25 5% $ Amazon.com $100 2.5% $ Menard's $25 3% $ Applebees $25 8% $ Menard's $100 3% $ Applebees $50 8% $ Menard's $500 (CAN ORDER) 3% $ Arbys $10 8% $ Mills Fleet Farm $25 3.5% $ Barnes & Noble $10 8% $ Mills Fleet Farm $100 3.5% $ Barnes & Noble $25 8% $ Old Chicago #25 6% $ Bath & Body Works $10 13% $ Olive Garden $25 8% $ Bath & Body Works $25 13% $ Panda Express $25 8% $ Best Buy $25 4% $ Panera Bread $10 8% $ Best Buy $100 4% $ Panera Bread $25 8% $ Bed Bath & Beyond $25 7% $ Pizza Hut $10 8% $ Buckle $25 8% $ Pizza Ranch $25 8% $ Buffalo Wild Wings $10 8% $ Red Lobster $25 8% $ Buffalo Wild Wings $25 8% $ Sally Beauty Supply $25 12% $ Burger King $10 4% $ Shopko $25 3% $ Cabela's $25 11% $ Shopko $100 3% $ Cabela's $100 11% $ Shutterfly $25 9% $ Caribou Coffee #10 6% $ Starbuck's $10 7% $ Casey's $10 3% $ Starbuck's $25 7% $ Casey's $25 3% $ Subway $10 6% $ Casey's $50 3% $ Subway $50 6% $ Chipotle Mexican Grill $10 10% $ TJ Maxx $25 7% $ Chuck E Cheese $10 8% $ TJ Maxx $100 7% $ Claire's $10 9% $ Target $25 2.5% $ Cold Stone Creamery $10 8% $ Target $50 2.5% $ Culvers $10 9% $ Target $100 2.5% $ Dairy Queen $10 3% $ Texas Roadhouse $25 8% $ Dick's Sporting Goods $25 8% $ Theisens $10 5% $ Dick's Sporting Goods $100 8% $ Theisens $25 5% $ Discover Card $50 1.25% $ Theisens $50 5% $ Discover Card $100 1.25% $ Theisens $100 5% $ Discover Card $250 1.25% $ Under Armour $25 11% $ Fareway $10 3% $ Visa $50 1.25% $ Fareway $25 3% $ Visa $100 1.25% $ Fareway $50 3% $ Visa $250 1.25% $ Fareway $100 3% $ Wal-Mart/Sam's Club $25 2.5% $ Fareway $200 3% $ Wal-Mart/Sam's Club $50 2.5% $ Gap/Banana R/Old Navy. $25 14% $ Wal-Mart/Sam's Club $100 2.5% $ Gap/Banana R/Old Navy. $100 14% $ Wal-Mart/Sam's Club $250 2.5% $ Great Clips $25 8% $ Wendy's $10 4% $ Hardee's $10 5% $ Younkers $25 8% $ Hy-Vee $10 3% $ Younkers $100 8% $ Hy-Vee $25 3% $ ON HAND WHILE SUPPLIES LAST Hy-Vee $50 3% $ Amazon $10 (90) 2.5% $ Hy-Vee $100 3% $ Applebees $10 (13) 8% $ Hy-Vee $200 3% $ Barnes & Noble $5 (25) 8% $ I Tunes $15 5% $ Chili's $25 (8) 11% $ I Tunes $25 5% $ Domino's $10 (3) 8% $ Jo-Ann Fabric & Craft $25 6% $ Domino's $25 (4) 8% $ Kmart $25 4% $ Olive Garden $10 (8) 8% $ Kmart $50 4% $ Outback $25 (1) 8% $ Kohls $25 4% $ Panera $5 (16) 8% $ Kohls $100 4% $ Red Lobster $10 (27) 8% $ Kwik Star $10 5% $ Shoe Carnival $25 (2) 5% $ Kwik Star $25 5% $ Starbuck's #5 (38) 7% $ Kwik Star $50 5% $ Target $10 (6) 2.5% $ Kwik Star $100 5% $ Wal-Mart/Sam's Club $10 (55) 2.5% $ Kwik Star $200 5% $ Kwik Star $500 (CAN ORDER) 5% $ Cascading Card File $3 Need something we don't keep on hand? - Go to www.shopwithscrip.com & click on the 'shop' tab for all national retailers. Indicate your request at the bottom of this page & attach your payment with this form..