Scrip Order Form

Pick up is available at the school during school hours. Pick up at the Rectory is available as follows:

Monday 1:00-4:00
Tuesday thru Friday 9:00-12:00 and 1:00-4:00

Accepted forms of payment are cash or check due at pick up.

Note: The % figures below are the amount of rebate the school receives from the merchant.

Name*
First Last
Phone*
(if we need to call you when your order arrives)
Purchase is for the _________ family.
Date*
Date Format: MM slash DD slash YYYY
Giant Eagle – 5% rebate
Price: $10.00 Quantity:
Giant Eagle – 5% rebate
Price: $25.00 Quantity:
Giant Eagle – 5% rebate
Price: $50.00 Quantity:
Giant Eagle – 5% rebate
Price: $100.00 Quantity:
Giant Eagle – 5% rebate
Price: $500.00 Quantity:
Applebees – 8% rebate
Price: $25.00 Quantity:
Arby's – 8% rebate
Price: $10.00 Quantity:
Bob Evan's – 10% rebate
Price: $10.00 Quantity:
Burger King – 4% rebate
Price: $10.00 Quantity:
Cracker Barrel – 9% rebate
Price: $10.00 Quantity:
Domino's Pizza – 8% rebate
Price: $10.00 Quantity:
Little Caesar's Pizza – 8% rebate
Price: $20.00 Quantity:
Logan's Roadhouse – 8% rebate
Price: $25.00 Quantity:
Olive Garden/Cheddars – 9% rebate
Price: $25.00 Quantity:
Original Pizza Place – 10% rebate
Price: $25.00 Quantity:
Outback – 8% rebate
Price: $25.00 Quantity:
Panera Bread – 9% rebate
Price: $10.00 Quantity:
Papa John's – 8% rebate
Price: $10.00 Quantity:
Pizza Hut – 9% rebate
Price: $10.00 Quantity:
Qdoba – 7% rebate
Price: $25.00 Quantity:
Red Lobster – 8% rebate
Price: $25.00 Quantity:
Ruby Tuesday – 8% rebate
Price: $25.00 Quantity:
Subway – 3% rebate
Price: $10.00 Quantity:
Texas Roadhouse – 8% rebate
Price: $25.00 Quantity:
Tim Horton's – 5% rebate
Price: $10.00 Quantity:
Wendy's – 8% rebate
Price: $10.00 Quantity:
BP – 1.5% rebate
Price: $50.00 Quantity:
Speedway – 4% rebate
Price: $25.00 Quantity:
Speedway – 4% rebate
Price: $100.00 Quantity:
Exxon – 1.5% rebate
Price: $50.00 Quantity:
Amazon – 4% rebate
Price: $25.00 Quantity:
Amazon – 4% rebate
Price: $100.00 Quantity:
American Eagle Outfitters – 10% rebate
Price: $25.00 Quantity:
Barnes & Noble – 9% rebate
Price: $10.00 Quantity:
Bath & Body Works – 13% rebate
Price: $10.00 Quantity:
Belk – 7% rebate
Price: $25.00 Quantity:
Claire's – 9% rebate
Price: $10.00 Quantity:
CVS Pharmacy – 6% rebate
Price: $25.00 Quantity:
CVS Pharmacy – 6% rebate
Price: $100.00 Quantity:
GAP/Old Navy/Banana Republic – 9% rebate
Price: $25.00 Quantity:
Greenleaf Landscape – 10% rebate
Price: $25.00 Quantity:
Home Depot – 4% rebate
Price: $25.00 Quantity:
iTunes – 7% rebate
Price: $15.00 Quantity:
JCPenny – 5% rebate
Price: $25.00 Quantity:
JoAnn Fabrics – 6% rebate
Price: $25.00 Quantity:
K-Mart – 4% rebate
Price: $25.00 Quantity:
K-Mart – 4% rebate
Price: $50.00 Quantity:
Kohl's Department Store – 4% rebate
Price: $25.00 Quantity:
Lands' End – 16% rebate
Price: $25.00 Quantity:
Lowe's – 4% rebate
Price: $25.00 Quantity:
Lowe's – 4% rebate
Price: $100.00 Quantity:
Payless Shoes – 13% rebate
Price: $20.00 Quantity:
Pier I Imports – 9% rebate
Price: $25.00 Quantity:
Rite Aid – 4% rebate
Price: $25.00 Quantity:
Sandy's Florist – 10% rebate
Price: $10.00 Quantity:
Talbot's – 13% rebate
Price: $25.00 Quantity:
Teri Ann's – 10% rebate
Price: $0.00 Quantity:
Any price (write amount in provided field)
Teri Ann's Amount
T-J Maxx – 7% rebate
Price: $25.00 Quantity:
Walmart – 2% rebate
Price: $25.00 Quantity:
Walmart – 2% rebate
Price: $100.00 Quantity:
Walmart – 2% rebate
Price: $250.00 Quantity:
Walgreen's – 6% rebate
Price: $25.00 Quantity:
Walgreen's – 6% rebate
Price: $100.00 Quantity:
Williams-Sonoma/Pottery Barn – 8% rebate
Price: $25.00 Quantity:
Scrip Gift Certificate – 5% rebate
Price: $0.00 Quantity:
Any price (write amount in provided field)
Scrip Gift Certificate Amount
Total
$0.00
Please check*
- By submitting this form I'm agreeing to the purchase of the selected cards.
Pick Up Location*
Pick Up Day*
Pick Up Time*