SCRIP Order Form - St. John the Baptist

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	St. John the Baptist Parish SCRIP Order Form
	Please enter your information and quantity of each SCRIP you would like to order. Click on the store names to view details about SCRIP. Once your order is placed, please bring your payment to the Parish Office unless you are paying by credit card (minimum order of $200).

First Name:		Last Name:
Phone:		Email:
Date:	2/5/2012	Delivery Method:


Grocery Stores	Profit	SCRIP	Qty	Subtotal
Buehler's Buy Low	5%	$25.00
Buehler's Buy Low	5%	$100.00
Gordon Food Service	4%	$25.00
Gordon Food Service	4%	$100.00
Rivertown Butcher	5%	$10.00


Grocery Stores	Profit	SCRIP	Qty	Subtotal
Rivertown Butcher	5%	$25.00
Wal-mart / Sam's	2%	$25.00
Wal-mart / Sam's	2%	$100.00
Wesselman's	5%	$10.00
Wesselman's	5%	$25.00


Retail Stores	Profit	SCRIP	Qty	Subtotal
Acropolis	15%	$10.00
Action Pest Control	10%	$50.00
Amazon.com	4%	$25.00
American Eagle	9%	$25.00
Applebee's	8%	$25.00
Arby's	8%	$10.00
Babies-R-Us / Toys-R-Us	1%	$20.00
Barnes & Noble	9%	$10.00
Barnes & Noble	9%	$25.00
Baskin Robbins	9%	$2.00
Bath & Body Works	13%	$10.00
Bath & Body Works	13%	$25.00
Bed Bath & Beyond	7%	$25.00
Best Buy	3%	$25.00
Biaggi's	10%	$20.00
Bob Evans	10%	$10.00
Bonefish / Outback	5%	$25.00
Borders	9%	$10.00
Borders	9%	$25.00
Build-A-Bear	8%	$25.00
Burger King	4%	$10.00
Cheeseburger in Paradise	5%	$25.00
Chili's	11%	$25.00
Chuck E. Cheese	8%	$10.00
Claire's	9%	$10.00
Cold Stone Creamery	8%	$10.00
Cornerstone Bookstore	10%	$10.00
Cracker Barrel	9%	$10.00
Culver 's	10%	$10.00
Culver 's	10%	$25.00
CVS Pharmacy	6%	$25.00
Denny's	7%	$5.00
Dick's Sporting	8%	$25.00
Dillard's	9%	$25.00
Domino's Pizza	5%	$5.00
Domino's Pizza	25%	$14.00
Don's Cleaners	6%	$10.00
Donut Bank	10%	$5.00
Donut Bank	10%	$10.00
Donut Bank	10%	$25.00
Edgewater Grille	15%	$10.00
Edgewater Grille	15%	$25.00
Fazoli's	7%	$25.00
G.D.Ritzy's	15%	$10.00
Gander Mountain	8%	$25.00
Great Harvest	8%	$10.00
Home Depot	4%	$25.00
Home Depot	4%	$100.00
iTunes	4%	$15.00
JCPenney	5%	$25.00
JCPenney	5%	$100.00
Jo Ann Fabrics	6%	$20.00


Retail Stores	Profit	SCRIP	Qty	Subtotal
KFC	9%	$5.00
Knob Hill	15%	$20.00
Kohl's	5%	$25.00
Kohl's	5%	$100.00
Land's End	17%	$25.00
Lic's	20%	$2.00
Limited	9%	$25.00
Logan's Roadhouse	8%	$25.00
Long John Silver's	8%	$5.00
Longhorn Steakhouse	9%	$25.00
Lowe's	4%	$25.00
Lowe's	4%	$100.00
Macy's	10%	$25.00
Macy's	10%	$100.00
Marshalls (T.J. Maxx)	7%	$25.00
Max & Erma's	13%	$20.00
Michael's	4%	$25.00
O'Charley's	13%	$25.00
Office Depot	4%	$25.00
Old Chicago	6%	$25.00
Old Navy / Gap	9%	$25.00
Olive Garden	9%	$25.00
Outback / Bonefish	5%	$25.00
Panera Bread	9%	$10.00
Payless Shoes	13%	$20.00
Pet Smart	4%	$25.00
Pier 1 Imports	9%	$25.00
Pizza Chef	10%	$10.00
Pizza Chef	10%	$20.00
Pizza Hut	8%	$10.00
Premiere Video	20%	$10.00
Red Lobster	9%	$25.00
Roca Bar (Archie & Clyde's)	10%	$10.00
Roca Bar (Archie & Clyde's)	10%	$25.00
Sears	4%	$25.00
Sears	4%	$100.00
Shoe Carnival	5%	$25.00
Staples	5%	$25.00
Starbucks	7%	$10.00
Starbucks	7%	$25.00
Subway	3%	$10.00
T.J. Maxx (Marshalls)	7%	$25.00
Texas Roadhouse	8%	$25.00
TGI Friday's	9%	$25.00
The Carousel	10%	$10.00
Thornton's	2%	$20.00
Thornton's	2%	$100.00
Tin Fish	10%	$10.00
Toys-R-Us	1%	$20.00
Walgreens	6%	$25.00
Weedman (Action Pest Control)	10%	$50.00
Wendy's	4%	$10.00

Payment

Check

Credit Card (Visa and MasterCard only)

Name on Card:
Card Number:
Billing Address:
Billing City:
Billing State:
Billing Zip:
Expiration Date:	/

On Hand SCRIP