SCRIP ORDER FORM

Concordia Lutheran School

Name

Phone #

As of 4/16/12

Delivery Method (circle one)

Send w/ Student

Hold for Pickup

Date

Email Address

Credit Earned

Participating retailers and products are subject  to change without notice.

Apparel & Accessories

Dining - Casual - con't

Product

%

Details

QTY

Total

Product

%

Details

QTY

Total

Aeropostale $25

7.00%

$

Denny's $10

7.00%

$

American Eagle Outfitters $25

10.00%

$

IHOP $25

8.00%

$

Buckle $25

8.00%

$

Jose's Blue Sombrero $5  (Paper Certificates)

20.00%

No Change

$

Dressbarn $25

8.00%

$

Noodles & Company $10

8.00%

$

Eddie Bauer $25

10.00%

$

Outback $25

8.00%

$

Finish Line $25

10.00%

$

Red Lobster/Olive Garden $25

9.00%

$

Foot Locker $25

9.00%

$

Red Robin $25

9.00%

$

Gap/Old Navy  $25

9.00%

$

Ruby Tuesday $25

8.00%

$

L.L. Bean $25

15.00%

No Payment on Account

$

Texas Roadhouse $25

8.00%

$

Lands' End  $25

16.00%/       18% to 5/25

Also good online/catalog

$

TGI Fridays $25

9.00%

$

Limited $25

9.00%

$

$

Men's Wearhouse $25

8.00%

No Payment on Account

$

Dining - On The Go

Payless Shoes $20

13.00%

$

Arby's $10

8.00%

$

Shoe Carnival $25

5.00%

$

Baskin Robbins $2

9.00%

$

Talbots $25

13.00%

No Payment on Account

$

Burger King $10

4.00%

$

TJ Maxx/Marshalls  $25

7.00%

$

Chipotle Mexican Grill $10

10.00%

$

TJ Maxx/Marshalls $100

7.00%

$

Cousins Subs $10

9.00%

$

Department Store

Culvers $10

10.00%

$

JCPenney  $25

5.00%

No pymnt on acct

$

Dairy Queen (Washington Ave. store only) - $1

20.00%

No Change

JCPenney $100

5.00%

No pymnt on acct

$

Dairy Queen (Washington Ave. store only) - $5

20.00%

No Change

$

Kohl's  $25

4.00%

Pymnt on acct.

$

Domino's $10

8.00%

$

Kohl's $100

4.00%

Pymnt on acct.

$

Dunkin' Donuts $10

4.00%

$

Macy's  $25

10.00%

$

Hardee's $10

5.00%

$

Sears  $25

4.00%

No pymnt on acct

$

KFC $5                                         (Paper Certificates)

8.00%

Change Given

$

Sears $100

4.00%

No pymnt on acct

$

Little Caesars $20

8.00%

$

Dining - Casual

Panera Bread  $10

9.00%

$

Applebee's $25

8.00%

$

Panera Bread $25

9.00%

$

Applebee's $50

8.00%

$

Papa Murphy's Pizza $10

8.00%

$

Boston Market $10

12.00%

$

Pizza Hut $10

8.00%

$

Buffalo Wild Wings $10

8.00%

$

Qdoba $25

7.00%

$

Buffalo Wild Wings $25

8.00%

$

Quiznos $10

10.00%

$

California Pizza Kitchen $10

4.00%

$

Starbucks $10

7.00%

$

Chancery $5                                                  (Paper Certificates)

20.00%

No Change

$

Starbucks $25

7.00%

$

Chili's $25

9.00%

$

Subway $10

3.00%

$

Chuck E. Cheese $10

8.00%

$

Subway $50

3.00%

$

Cracker Barrel $10

9.00%

$

Taco Bell $10

5.00%

$

Cracker Barrel $25

9.00%

$

Wendy's $10

4.00%

$

Discount Store

Home Decor

Product

%

QTY

Total

Product

%

QTY

Total

Kmart $25

4.00%

$

Bed Bath & Beyond $25

7.00%

$

Kmart $50

4.00%

$

Home Improvement

Shopko $25

3.00%

$

Home Depot  $25

4.00%

$

Shopko $50

3.00%

$

Home Depot $100

4.00%

$

Target GiftCard  $25

2.00%

$

Lowe's   $25

4.00%

$

Target GiftCard $100

2.00%

$

Menards  $25                                                  (Paper Certificates)

3.00%

No Payment on Account

$

Walmart/Sam's Club  $25

2.00%

$

Menards  $100                                                  (Paper Certificates)

3.00%

No Payment on Account

$

Walmart/Sam's Club  $100

2.00%

$

Online & Mail Order

Electronics & Office

Amazon.com  $25                                                   (Paper Certificates)

4.00%

$

Best Buy   $25

3.00%

$

iTunes $15

5.00%

$

BEST BUY  $100

3.00%

$

iTunes $25

5.00%

$

GameStop $25

3.00%

$

Nike $25

12.00%

$

Office Depot  $25

4.00%

$

Specialty Retailer

Office Max  $25

5.00%

$

Bath & Body Works  $10

13.00%

$

Entertainment

Bath & Body Works $25

13.00%

$

Barnes & Noble  $10

9.00%

$

CVS/pharmacy  $25

6.00%

$

Barnes & Noble  $25

9.00%

$

CVS/pharmacy $100

6.00%

$

Barnes & Noble $100

9.00%

$

GNC $25

8.00%

$

Blockbuster $10

7.00%

$

Great Clips $25

8.00%

$

Family Video $10

12.00%

$

Hallmark $25

4.00%

$

Marcus Theatres/Resort  $25

9.00%

$

Jo Ann Fabrics $25

6.00%

Change Given

$

Marcus Theatres/Resort $100

9.00%

$

Michael's  $25

4.00%

$

Gas & Auto

Pier One Imports  $25

9.00%

No Payment on Account

$

AutoZone $25

8.00%

$

The Container Store  $25

9.00%

$

BP Gas Stations  $50

1.50%

$

Toys R Us/Babies R Us $20

1.50%

$

BP Gas Stations $100

1.50%

$

Walgreens  $25

6.00%

$

Exxon/Mobil  $50

1.50%

$

Walgreens $100

6.00%

$

Jiffy Lube $30

8.00%

$

Sporting Goods

Kwik Trip  $25

4.00%

9% thru 12/30

$

Bass Pro Shops  $25

9.00%

$

Kwik Trip $100

4.00%

9% thru 12/30

$

Cabela's $25

11.00%

$

Shell  $50

2.50%

$

Dick's Sporting Goods $25

8.00%

$

Shell $100

2.50%

$

Gander Mountain $25

8.00%

$

Speedway/SuperAmerica  $25

4.00%

$

Sports Authority  $25

8.00%

$

Speedway/SuperAmerica $100

4.00%

$

Other Vendors Not Listed on form but Available

Grocery

%

$

Pick 'n Save $25

4.00%

$

%

$

Pick 'n Save $50

4.00%

$

Pick 'n Save $100

4.00%

$

Grand Total

No. of Items

 $

Piggly Wiggly $25

3.00%

$

Total Due

Piggly Wiggly $50

3.00%

$

Make Checks Payable To:

Piggly Wiggly $100

3.00%

$

Concordia Lutheran School PTL

Sentry $10 OR $50                          (Paper Certificates)

3.00%

No Change Given

$

Woodman's $50

5.00%

$

For additional vendors and/or details go to www.glscrip.com

Woodman's $100

5.00%

$

to view the retailer list.