SCRIP ORDER FORM
Scrip Credit to be given to ____________________________ Date________________
Phone Number__________________________E-mail____________________________
Check # & Amount_____________________________________
I give my child permission to bring my scrip order home__________________________
|
Retailer |
Cert. Amount |
# of Cert. |
% |
Total |
|
Cousin’s |
$5.00 |
|
8% |
|
|
Culver’s |
$10.00 |
|
10% |
|
|
Fleet & Farm |
$25/$50/$100 |
|
5% |
|
|
Jumbo’s Frozen Custard |
$10.00 |
|
8% |
|
|
Kohl’s (use to pay off Kohls charge card) |
$25/$50/$100 |
|
4% |
|
|
McDonald’s |
$5.00 |
|
5% |
|
|
Mineshaft Dining |
$10.00 |
|
8% |
|
|
Subway |
$10.00 |
|
3% |
|
|
Pick ‘n Save |
$25.00 |
|
3% |
|
|
Dairy Queen |
$1.00 |
|
10% |
|
|
|
|
|
|
|
|
|
|
GRAND TOTAL |
|
|