OFFICE USE: Columbus Catholic Received by: Date: SCRIP ORDER FORM Filled by: Date: Please make checks payable to: Entered by: Date: GIFT CARD PROGRAM Purchaser:____________________________________________________DATE:______/______/______ Phone:_(_____)_________________Email:____________________________________Check #:_________Cash Order Pick Up Options: Hold at Scrip Office Pick Up at School:_______________________________________________________________________ Send Home with CCS Student (Name & Bldg):_________________________________________________ MUST HAVE A SIGNED AUTHORIZATION FORM ON FILE! Credit My Scrip Benefits to: Family Fee/Tuition Family Name:_____________________________________________________ OLP Parish SJB Parish SH Parish Corpus Christi Ms. B Memorial Scholarship Tuition Assistance Customer Signature: _______________________________________________________________________ See Back of form for Ordering Information Note: Rebates are subject to change Check www.shopwithscrip.com for a complete list of over 750 retailers available! Rev. 7/19 Scrip-To-Go Order Form Product Rebate Qty Ext Price Product Rebate Qty Ext Price 2-1/2 Cups Cupcakery & Bakeshop $15 20.00% Little Caesars $20 8.00% *Advance Auto Parts $25 or $100 7.00% Lumberyard Bar & Grill $25 10.00% Amazon.com $25 2.25% * Mall Furniture ($ per request) 4.00% Applebee's $25 8.00% * Marshfield Country Club ($ per request) 8.00% Arby's $10 8.00% Maurices $20 7.00% * Avon ($ by request) Alexis Vine 10.00% McDonalds $5 5.00% Baltus Gas $10 10.00% McDonalds $10 5.00% Bath & Body Works $10 12.00% McDonalds $25 5.00% Biggby Coffee $10 20.00% MENARDS $25 (LOCAL) 4.00% Blue Heron B&P/W.14th $20 8.00% MENARDS $100 (LOCAL) 4.00% * Blue's Hair Studio ($20 or $ by request) 5.00% Mission Nutrition $25 5.00% * Bull's Eye Sport Shop ($ per request) 5.00% * Mittens Furn, Appl & Elec ($ per request) 3.00% Burger King $10 4.00% Nutz Deep II $25 10.00% Carl's Jr./Hardee's $10 5.00% * Off the Wall Custom Framing ($ per req) 10.00% * Carpet Warehouse & Flooring ($ by request) 5.00% * Pampered Chef $25/per req (Andrea Bauer) 10.00% China Chef $10 20.00% Papa Murphy's Pizza $10 8.00% Chips $5 20.00% * Paul Tishim Photographic Artist ($ per req) 5.00% * Claire's $10 9.00% Perkins $10 13.00% Coffee Cabin $10 5.00% Perkins $25 13.00% * Country Aire $10 or $25 8.00% Pizza Hut $10 8.00% Crabby Dave's $10 10.00% Red Robin $25 8.00% Culver's $10 6.00% Roger's Cinema $8 12.50% Culver's $50 6.00% Roundy’s/Pick n Save/Mariano $25 (IL/WI) 4.00% DAIRY QUEEN $10 (LOCAL) 10.00% Roundy's/Pick n Save/Mariano $100 (IL/WI) 4.00% * Deborah Ann's Home Décor&Gifts ($ per req) 5.00% * Sally Beauty Supply $25 12.00% Dick's Sporting Goods $25 8.00% * Scentsy by Mollie Laidlaw ($ per request) 10.00% Domino's $10 8.00% Schierl Tire/The Store $25 5.00% Dunham's Sports $25 8.00% Schierl Tire/The Store $100 5.00% Dunkin' Donuts $10 3.00% Scotty's Pizza $10 20.00% El Mezcal (local) $10 10.00% * Stampin' Up by Elizabeth Giles ($ per req) 5.00% * Eyecare Center of Mfld ($ per request) 5.00% Starbucks $10 7.00% Family Video $10 12.00% * St. Vincent de Paul ($ per request) 5.00% Festival Foods (WI) - Skogens $50 3.00% Subway $10 6.00% Festival Foods (WI) - Skogens $100 3.00% Subway $50 6.00% Fleet Farm $25 4.76% Taco Bell $10 5.00% Fleet Farm $100 4.76% Target $25 2.50% * Furniture and Appliancemart ($ per req) 3.00% Target $100 2.50% * Game Stop $25 3.00% * The Sports Den $50 or $100 10.00% * GNC $25 8.00% * Tradition Cleaners ($ per request) 15.00% * Great Clips $25 8.00% Victory Apparel $10 20.00% Hiller's True Value $25 10.00% Vintage House $20 20.00% iTunes $15 5.00% WALGREENS $25 5.00% Jo Ann Fabrics $25 6.00% Walmart/Sam's Club $25 2.50% KOHL'S $25 (LOCAL) 5.00% Walmart/Sam's Club $100 2.50% KOHL'S $100 (LOCAL) 5.00% Weber's Farm Store $10 4.00% KWIK TRIP $25 (LOCAL) 5.00% * Weiland Inspection Services ($ per req) 5.00% KWIK TRIP $50 (LOCAL) 5.00% Weilers $10 10.00% KWIK TRIP $100 (LOCAL) 5.00% Weiler's Car Wash $10 20.00% Libby McNeill's/Hotel Marshfield $25 10.00% *Wibben Photography ($ per req) 2.00% *Wickersham Jewelry ($1, $25, $50, $100) 10.00% * These vendors are local but need to be ordered by 9 a.m. Mondays for delivery by Thursday. TOTAL: ___________________________ (Turn Over To Complete Purchaser Information).