SCRIP ORDER FORM

_______________________ _______/___________ _______________ ____________

Customer Name (Last, First) Organization/Acct # Phone Number Order Date

RETAILER % $ QTY TOTAL RETAILER % $ QTY TOTAL

Ace Hardware 4% 25 Chuck E Cheese 8% 10

Advance Auto Parts 7% 25 Claire's/Icing 9% 10

Aéropostale 7% 25 Cold Stone Creamery 8% 10

Allied Waste 10% 20 Comfort/Quality Hotels 4% 25

Allied Waste 10% 100 Cracker Barrel 9% 10

American Eagle 9% 25 Crystal Flash 2% 50

American Express GIFT Card 1.25% 100 Culvers 10% 10

Applebee's 8% 25 CVS Pharmacy 6% 25

Arby's 8% 10 Denny's 7% 10

Auto Zone 5% 25 Dick's Sporting Goods 8% 25

Barnes & Noble ���� 9% 10 Dining Concepts � 5% 25

Barnes & Noble ���� 9% 25 Disney 2% 25

Baskin Robins 9% 2 Dress Barn 8% 25

Bass Pro Shop 9% 25 Dunkin Donuts 4% 10

Bath & Body 13% 10 Exxon/Mobil 1.5% 50

Bath & Body 13% 25 F.Y.E 6% 25

Bed Bath & Beyond 7% 25 Family Christian 9% 25

BedandBreakfast.com 10% 50 Family Fare/Spartan 3% 25

Beltline Bar/Sundance Grill 5% 25 Family Fare/Spartan 3% 50

Best Buy 3% 25 Family Fare/Spartan 3% 100

Best Western 12% 25 Family Video 10% 10

Big Apple Bagel 10% 5 Fannie Mae/1-800-Flowers 25% 10

Blockbuster 7% 10 Fazoli's 7% 25

Boston Market 12% 10 Frosty Treat 10% 1

BP 2% 50 Gander Mountain 8% 25

Brann's 9% 10 Gap/Old Navy/Banana Rep. ���� 9% 25

Build-A-Bear Workshop 8% 25 GFS 4% 25

Burger King 4% 10 GNC 8% 25

Celebration/Loeks Cinema 4% 10 Grandvilla 9% 10

Celebrity Cruises 9% 100 Hallmark 4% 25

Chili's 11% 25 Home Depot 4% 25

CK# __________ Grand Total________

Cash Amt. ______ Received By: ______

Order Filled By: _______________

Symbols: � � � � � � � � � ���� ����

KEY on back/page 2

To ensure accurate gift rebate percentages, visit www.shopwithscrip.com

Rev. 9/09

More gift card denominations, and different merchants,

can be found at

www.shopwithscrip.com

J

RETAILER % $ QTY TOTAL RETAILER % $ QTY TOTAL

Home Depot 4% 100 Potluck 5% 10

Home Depot 4% 500 Potluck 5% 30

Honey Baked Ham 12% 10 Qdoba 7% 25

Hyatt Hotels 9% 25 Rainbow 5% 25

Itunes 4% 15 Red Lobster/Olive Garden 9% 25

JC Penney 5% 25 Red Robin 9% 25

JC Penney 5% 100 Regis Salons 8% 25

Jenison Car Wash 25% 6 Rite Aid 4% 25

JoAnn Fabrics 6% 20 Ruby Tuesday's 8% 25

KFC 9% 5 Ryan's/Fire Mountain 5% 25

Kohl's � 4% 25 Sally Beauty Supply 12% 25

Kohl's � 4% 100 Sears 4% 25

L.L. Bean 15% 25 Sears 4% 100

Land's End 17% 25 Sheldon Cleaners 9% 5

Lane Bryant/Fashion Bug 6% 25 SpaFinder 12% 25

Little Caesars 8% 20 Speedway (Fuel Only) 5% 10

Logans 10% 25 Speedway 5% 25

Long John Silvers 8% 5 Speedway 5% 50

Lowes Hardware ���� 4% 25 Speedway 5% 100

Lowes Hardware ���� 4% 100 Software Etc./GameStop 3% 25

Lowe's Hardware 4% 500 Staples 5% 25

Macy's 10% 25 Starbucks ���� 7% 10

Marriott Hotels 8% 50 Starbucks ���� 7% 25

Maui Jim’s Polarized Sunglasses 15% 25 Steak & Shake 8% 10

Max & Ermas 13% 20 Subway 3% 10

MC Sports 8% 25 SuperCuts 8% 25

Menard's Home Center 3% 25 T.J. Maxx/Marshall's 7% 25

Menard's Home Center 3% 100 Texas Roadhouse 8% 25

Micheal's 4% 25 TGI Friday 9% 25

Office Max 5% 25 V&V Nursery 10% 10

Old Country Buffet 5% 25 VIP 4% 5

Olga's Kitchen 8% 20 VIP 4% 25

Outback Steakhouse/Carrabas 5% 25 VIP Scrip���� 4% 1

Palermos 20% 5 VISA Rewards 2% 25

Panera 9% 10 Wal Mart/Sam's Club 2% 25

Papa John's ���� 8% 10 Wal Mart/Sam's Club 2% 100

Payless Shoes 13% 20 Walgreens 7% 25

Perkins 17% 10 Walgreens 7% 100

Petsmart 4% 25 Wendy's 4% 10

Pizza Hut 8% 10 Younkers/Elder-Beerman 8% 25

KEY:

���� = BONUS Gift Rebate

���� = VIP Scrip checks must be for at least $200.

� = Accept gift cards as payment towards a bill.

� = Rio Grand Steakhouse, The B.O.B., Blue Water Grill, Boatwerks, NOTO’s - visit www.diningconcept.com for a complete list of participants.

���� = Reloadable Gift Card on www.shopwithscrip.com

PLEASE DOUBLE CHECK YOUR ORDER BEFORE PLACING IT. Rev. 9/09