| % |
Merchant |
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% |
Merchant |
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| 9 |
American Eagle Outfitters ($25) |
$________ |
4 |
Michael's Crafts ($25) |
$________ |
|
| 1.2 |
American Express ($100) Good at Costco |
$________ |
4 |
Office Depot ($25) |
$________ |
|
| 20 |
Angelo's Pizza ($5, $10, $20) |
$________ |
9 |
Old Navy / Gap / Banana Republic ($25) |
$________ |
|
| 10 |
Applebee's ($25) |
$________ |
9 |
Olive Garden ($25) |
$________ |
|
| 2 |
Arco ($50) |
$________ |
3 |
Outback Steakhouse ($25) |
$________ |
|
| 9 |
Barnes & Noble ($10, $25) |
$________ |
60 |
U-Top-It ($5) |
$________ |
|
| 9 |
Baskin & Robbin ($2) |
$________ |
9 |
Red Lobster ($25) |
$________ |
|
| 13 |
Bath & Body Works ($10, $25) |
$________ |
9 |
Red Robin ($25) |
$________ |
|
| 7 |
Bed Bath & Beyond ($25) |
$________ |
2 |
Rite Aid ($25) |
$________ |
|
| 2 |
Best Buy ($25) |
$________ |
8 |
Ross Dress For Less ($25) |
$________ |
|
| 8 |
Big 5 Sporting Goods ($25) |
$________ |
10 |
Round Table Pizza (not good at Mt. Shasta Mall) ($5, $10) |
$________ |
|
| 7 |
Blockbuster ($10) |
$________ |
3 |
Safeway ($25, $100) |
$________ |
|
| 4 |
Burger King ($10) |
$________ |
15 |
Scrip Wallets ($1) holds all of your scrip |
$________ |
|
| 10 |
Burrito Bandito ($10) |
$________ |
4 |
Sears ($25) Can use at Orchard Supply Hardware |
$________ |
|
| 9 |
Carl's Jr. ($5 & $10) |
$________ |
25 |
See's Candies ($15.00 per pound) |
$________ |
|
| 1.5 |
Chevron ($50) |
$________ |
1.5 |
Shell ($50) |
$________ |
|
| 4 |
Cinemark (Movies 8 & 10) ($25) |
$________ |
4 |
Shopko ($25) |
$________ |
|
| 10 |
Cool Hand Luke's ($25) |
$________ |
8 |
Sports Authority ($25) |
$________ |
|
| 8 |
Cold Stone Creamery ($10) |
$________ |
7 |
Starbucks ($10, $25) |
$________ |
|
| 2 |
CVS Pharmacy ($25) |
$________ |
3 |
Subway Sandwich ($10) |
$________ |
|
| 7 |
Denny's ($10) |
$________ |
1.2 |
Trader Joe's ($25) |
$________ |
|
| 2 |
Food Maxx ($25, $100) |
$________ |
1.2 |
Target ($25) |
$________ |
|
| 8 |
Great Harvest Bread ($10) |
$________ |
7 |
TJ Maxx ($25) |
$________ |
|
| 20 |
Guadalajara Restaurant ($20) |
$________ |
2 |
Walgreens ($20 & $25) |
$________ |
|
| 20 |
La Cabana Restaurant ($20) |
$________ |
2 |
Walmart ($25 & $100) |
$________ |
|
| 10 |
Holiday Market ($20, $50) |
$________ |
9 |
Wendy's ($10) |
$________ |
|
| 3 |
Home Depot ($25, $100) |
$________ |
|
TOTAL AMOUNT ENCLOSED: |
$_________ |
|
| 4 |
Itunes ($15) |
$________ |
|
|
check____cash_____ |
|
| 7 |
Jamba Juice ($10) |
$________ |
|
Scrip % subject to change. |
|
|
| 5 |
JC Penney ($25, $100) . |
$________ |
|
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|
| 9 |
Kentucky Fried Chicken ($5) |
$________ |
|
Name:__________________________________ |
|
|
| 2 |
Kmart ($25) |
$________ |
|
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|
|
| 4 |
Kohl's ($25 & $100) Use for Kohls card pmt. |
$________ |
|
Daytime Phone:__________________________ |
|
|
| 10 |
Logan's Roadhouse ($25) |
$________ |
|
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|
| 4 |
Lowe's Hardware ($25, $100) |
$________ |
|
How would you like to pick up your scrip? |
|
|
| 10 |
Lumberjack's Restaurant ($25) |
$________ |
|
Put in child's backpack ______ Pick Up
After School______ |
|
| 9 |
Macy's ($25, $100) |
$________ |
|
If you have any questions, or if I can be of any assistance, please call |
|
| 5 |
McDonald's ($5) |
$________ |
|
Terri Misslin at 243-2302 . |
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updated 1/12/10 |
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