Scrip order form

Sponsor Name	Denominations Available	Amount Purchased
Department Stores (5%)
American Airlines	$50.00	___
American Eagle	$25.00	___
Ames	$10.00	___
AT&T Card (60 minutes)	$15.00	___
August Max Woman	$10.00	___
Banana Republic	$25.00	___
Barnes & Noble	$10.00	___
Bath & Body Works	$10.00	___
B. Dalton Bookstore	$10.00	___
Blockbuster	$10.00	___
Borders	$10.00	___
Cacique	$10.00	___
Casual Corner	$10.00	___
Chambers *	$20.00	___
Eddie Bauer	$25.00	___
Express	$10.00	___
Footlocker	$10.00	___
Gap / Gap Kids	$25.00	___
Gardener's Eden *	$20.00	___
Hold Everything *	$20.00	___
Hollywood Video	$3.49 each	___
Hyatt Hotels	$25.00	___
J C Penney	$10, $25, $100	___
KB Toys	$10.00	___
Land's End	$25.00	___
Lillian Vernon	$20.00	___
Limited	$10.00	___
Loews Theaters	$5.00	___
Macy's	$25.00	___
Marriott Hotels	$25.00	___
Marshall's / TJ Maxx	$10, $25	___
Music Land /Suncoast	$10.00	___
Old Navy	$25.00	___
Payless Shoes	$20.00	___
Petite Sophisticate	$10.00	___
Pier One Imports	$10, $25	___
Pottery Barn *	$20.00	___
Sam Goody	$10.00	___
Spiegel	$25.00	___
Structure	$25.00	___
Waldenbooks	$10.00	___
Warner Brothers	$10.00	___
Williams Sonoma *	$20.00	___
Restaurants (5%)
Applebee's	$10.00	___
Baskin Robbins	$2.00	___
Bennigan's	$10.00	___
Bob Evans	$5.00	___
California Pizza Kitchen	$5.00	___
Carlos O'Kelley	$10.00	___
Chi Chi's	$10.00	___
Chili's	$10.00	___
Chuck E. Cheese	$10.00	___
Cracker Barrel	$5.00	___
Denny's	$5.00	___
Domino's	$5.00	___
Honey Baked Ham	$10.00	___
Kentucky Fried Chicken	$5.00	___
Mrs. Field's Cookies	$5.00	___
Outback	$35.00 dinner for two	___
Pizza Hut	$5.00	___
Red Lobster / Olive Garden	$10.00	___
Ruby Tuesday's	$10.00	___
Red Robin	$10.00	___
Steak & Ale	$10.00	___
TGI Friday's	$10.00	___
Wendy's	$5.00	___
Reduced Discount
Best Buy 2%	$10, $50	___
BP Gas 3.5%	$25, $100	___
Burger King 4%	$5.00	___
Circuit City 3%	$50, $100	___
Citgo 3%	$25.00	___
Exxon 3%	$25.00	___
Home Depot 3%	$25, $100	___
KMart 3%	$25, $100	___
Lowe's 3%	$25, $100	___
Office Max 4%	$10, $25	___
Penske Auto Center (KMart) 3%	$10, $25, $50	___
Sears 2%	$25, $100, $250	___
Shell 2%	$25, $100	___
Toys R Us / Kids R Us 3%	$10.00	___
Grocery Stores (5%)
Giant	$5, $10, $20	___
Shoppers	$20.00	___
Total Order _______

Scrip Order Form

Sponsor Name

Denominations Available

Amount Purchased

Department Stores (5%)

Restaurants (5%)

Reduced Discount

Grocery Stores (5%)

Total Order _______

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