Printable Order Form (PDF) - Saint Charles Borromeo Catholic Church

ST. CHARLES SCRIP (Substitute Currency Reaps in Profits) Certificate Order Form
Date: __________ Name: ______________________________ Envelope No. _________ Phone (Day) __________________
DELIVERY: (1)_____ Pick up at Parish Office after 2:00 p.m. on Monday: (2)_____ Pick up Cash Sales on Sun.
(3) Send home with ____________________Grade/Room ____________(4) * *Mail to __________________________________________* *
* * Not responsible for any mail not delivered by the Post Office.
Groceries % $25 $50 $100 $250 TOTAL
Gordon’s (GFS) 4%
Kroger/Scott’s 3%
Kroger/Scott’s 3% $10
Meijer 4%
Meijer 4% $10
Wal-Mart/Sam’s 2.5%
Dave Hills 5% $10
Honey Bked Ham 12%
Jamison Meats 5%
RELOADABLE GIFT CARD $50
Check Amt: ______________
Cash _____________
No. __________ Charge __________
Gift Card __________
Gas/Automotive % $10 $25 $50 $100 TOTAL
BP Gas/Amoco 1.5%
$$ Hires Auto Parts 10%
Jiffy Lube 11% $30
Lassus Handy Dandy 4%
Marathon 3%
Marathon 4% $250
Mikes Car Wash 38% $8
See SCRIP Coordinator
N. Haven Meats 3%
Restaurants % $5 $10 $25 TOTAL
800 Degrees Pizza 10%
Applebees 10%
Arby’s 8%
Atz’s Ice Cream 8%
Azteca Mexican Rest 10%
B. Antonios 10%
Bagel Station 15%
Baker Street 10% $50
Bandidos 10% $20
Blue Stack Smokehouse 10%
Bob Evans 10%
Bon Bon’s (Higher Ground) 4%
Buffalo Wild Wings 8%
Buffalo Wings/Ribs 5%
Burger King 4%
Carlos O’Kelley 9%
Casa Restaurants 5%
Casa Grande 9%
Cebolla’s 9%
Cheddar’s 9%
Cheesecake Factory 5%
Chili’s 11%
Chipotle 10%
Chuck E Cheese 8%
Club Soda 10%
Cocktails 10%
Cold Stone Creamery 8%
Cookie Cottage 10% $12
Cosmos 10%
Cracker Barrel 9%
Culver’s 10%
Debrand Chocolate 10%
Dicky’s Wild Hare 10%
Dunkin Donut 10%
Famous Recipe 10%
Fazoli’s 9%
Fish of Stroh 5%
Golden Corral 10%
Granite City 9%
Hall’s Restaurant 5%
IHOP 10%
Jets Pizza 10%
KFC 8%
La Margarita’s 20%
Shell Prepaid 2.5%
Speedway 5%
Speedway 5% $250
$$ Tom Steele Tires 5%
Restaurant Cont % $5 $10 $25 TOTAL
Logans Roadhouse 8%
Lucky Moose 10%
$$ Lunch Box Cafe 10%
Mancino’s 10%
Mandarin 10%
Marcos Pizza 15%
McDonald’s 5%
Noodles & Co. 8%
Noodle Bowl 10%
O’Charley’s 13%
Olive Garden/Red Lobster 9%
$$ Outback 8%
Panera 9%
Papa John’s 8%
Papa Murphy’s Pizza 8%
Penn Station 10%
Pine Valley Bar & Grill 8% $20
Pizza Hut 8%
Qdoba 7%
Rack & Helen’s 10%
Red Robin Rest 9%
Richards 10% $20
Rich’s Cafe 10%
Ruby Tuesday’s 8%
Salsa Grill 10%
Salvatori’s 10%
Starbucks 7%
Steak & Shake 10%
Subway - Canterbury &
Dupont Only
10%
Subway 3%
Taco Bell 5%
Texas Roadhouse 10%
TGI Friday 9%
The Pizza Forum 10%
$$ Trion Tavern 10%
Wendy’s 4%
Willie’s Restaurant 5%
Wings., Etc. 4%
Wise Guys Italian Ice 10%
Zesto 10%
Ziano’s 15%
See SCRIP Coordinator
Laycoff’s 15%
Little Caesar’s 8% $20
TOTAL FOR FRONT $
www.glscrip.com
www.stcfw.org

Sports &
Entertainment % $5 $10 $25 TOTAL
Bobick’s 10%
Cinema Grill 5%
Game Stop 3%
Georgetown Bowl 5% $25
Glen Aqua 5%
iTunes 5% $15
Park Forest 7%
Regal Theaters 8%
Roller Dome 10%
Ultra Zone 46% $6
$100
Home Imp/Services % $10 $25 $50 $100 TOTAL
Atlantis Pools & Spas 5%
Ciocca Cleaning 10%
DuHadway 2%
Henry’s Greenhouse 10% $$
Home Depot 4%
Lowe’s 4%
Menard’s 4%
$$ Stanley Steamer 5%
$$Steamatic Carpet Clg 6%
Retail Stores % $10 $25 $50 $100 TOTAL
Abba House 10%
Aeropostale 7%
All Saints Religious 10%
Amazon 3%
American Eagle 10%
Barnes & Noble 9%
See SCRIP Coordinator
Can not be used for parties
See SCRIP Coordinator
See SCRIP Coordinator
Retail Stores % $10 $25 $50 $100 TOTAL
Journey 13%
K Mart 4%
Kohl’s-Can PayCharge 5%
Kyrou Tailoring 10%
$$ LL Bean 16%
Land’s End 16%
$$ Lopshire Flowers 10%
Macy’s 10%
Master Cleaners 10%
$$ MCSports 8%
Michael’s 4%
Office Depot 4%
Old Navy/Gap 14%
Payless Shoe Source 13% $20
Peerless Cleaners 5% $5 $20
Pet Smart 4%
$$ Pier One Imports 9%
$$ Pottery Barn/Wm
Sonoma
8%
Prof Village 6002 Salon 10%
Regis/Famous Hair 8%
Sally Beauty Supply 12%
$$ Sears 4%
$$ Shoe Carnival 5%
$$ Talbots 13%
Target (No Charge) 2%
TJ Maxx/Marshalls 7%
Toys/Babies/R Us 1.5% $20
ULTA 4%
United Art & Edu 10%
Walgreens 6%
Wild Birds Unlimited 5%
Bath & Body Works 13%
Bed, Bath & Beyond 7%
Best Buy— No Charge 3%
$$ Build A Bear 8%
Carmen & Company 10%
Children’s Place 12%
Claire’s/Icings 9%
Coldwater Creek 10%
$$ Crate & Barrel 8%
Travel % $50 $100 TOTAL
Choice Hotels 4%
Marriott Hotels 8%
$$ Avis Rent A Car 8%
$$ Budget Rent A Car 8%
St. Charles SCRIP Gift Certificates are available. The certificates make great gifts as
the receiver can choose the items they want. The person redeeming the certificate
receives the SCRIP credit.
Crazy 8 13%
CVS Pharmacy 6%
Dick’s Sporting Gds 8%
DSW 9%
Express 10%
Fred Toenges 10%
Gander Mountain 8%
$$ Gordman’s 7%
Great Clips 8%
Certificate Number
TOTAL (FRONT) $
TOTAL (BACK) $
TOTAL ORDER $
Amount
Gymboree 13%
Hallmark 4%
$$ Healthkick 8%
JC Penney (No Charge) 5%
JoAnne’s 6%
SCRIP CASH SALES-Hession Center will be 8:00 a.m. - 9:00 a.m.;
Main Entrance of Church, Saturday, after the 5:00 p.m. Mass and
Sunday, after the 9:00 a.m. Mass and before the 11:00 a.m. Mass.
Please make check payable to ST. CHARLES SCRIP
Charge to my MASTERCARD OR VISA (Circle one) Sec. Code ________
Account No: ______________________________
Expiration Date: ______________ Total Charge:_________________:
Signature ________________________________________________
Fees incurred from charging your purchase (3.61% of the total
charge plus (12 cents) will be deducted from the profit before the
Education Credit is calculated.
The following merchants are available upon request: Ace Hardware, Best Western Hotels, Burlington Coat Factory, Cabela’s, Carnival Cruise Lines,
Current Mechanical, Didier Meat, Disney/Disney Travel, Dominos, Dr. Steven Hoagburg, Dr. Mark Stoner, DDS, Eddie Bauer, Family Christian Store,
Finish Line, Footlocker, Forever Friends Floral, Frame Art, Guitar Center, J. Crew, L & S Alignment, Long John Silvers, Maurices, McMahon Tire & Auto,
Motherhood Maternity, Orthodontic Specialty Services, Party Poopers, Pine Ridge Racquet, Radio Shack, R-N-B Sounds (DJ), Ruhl Furniture, Simply
Unforgettable(Video), Staples, Waiter on the Way, Winn-Dixie, Wisman’s Appliances.
Special Orders for merchants in above box :
Merchant __________________________Denomination _________Quantity______
Merchant __________________________Denomination _________Quantity______
$$ PLAN AHEAD $$ Merchant certificates that are not always
on hand but can be obtained by Thursday.
Please contact a SCRIP coordinator with any questions; the SCRIP Office, 969-
4027, Peggy, 486-4190, Madonna, 485-7501.
06/05/2013