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*
MM slash DD slash YYYY
Giant Eagle – 5% rebate
Price: $10.00
Giant Eagle – 5% rebate
Price: $25.00
Giant Eagle – 5% rebate
Price: $50.00
Giant Eagle – 5% rebate
Price: $100.00
Giant Eagle – 5% rebate
Price: $500.00
Applebees – 8% rebate
Price: $25.00
Arby's – 8% rebate
Price: $10.00
Bob Evan's – 10% rebate
Price: $10.00
Burger King – 4% rebate
Price: $10.00
Cracker Barrel – 9% rebate
Price: $10.00
Domino's Pizza – 8% rebate
Price: $10.00
Little Caesar's Pizza – 8% rebate
Price: $20.00
Logan's Roadhouse – 8% rebate
Price: $25.00
Olive Garden/Cheddars – 9% rebate
Price: $25.00
Original Pizza Place – 10% rebate
Price: $25.00
Outback – 8% rebate
Price: $25.00
Panera Bread – 9% rebate
Price: $10.00
Papa John's – 8% rebate
Price: $10.00
Pizza Hut – 9% rebate
Price: $10.00
Qdoba – 7% rebate
Price: $25.00
Red Lobster – 8% rebate
Price: $25.00
Ruby Tuesday – 8% rebate
Price: $25.00
Subway – 3% rebate
Price: $10.00
Texas Roadhouse – 8% rebate
Price: $25.00
Tim Horton's – 5% rebate
Price: $10.00
Wendy's – 8% rebate
Price: $10.00
BP – 1.5% rebate
Price: $50.00
Speedway – 4% rebate
Price: $25.00
Speedway – 4% rebate
Price: $100.00
Exxon – 1.5% rebate
Price: $50.00
Amazon – 4% rebate
Price: $25.00
Amazon – 4% rebate
Price: $100.00
American Eagle Outfitters – 10% rebate
Price: $25.00
Barnes & Noble – 9% rebate
Price: $10.00
Bath & Body Works – 13% rebate
Price: $10.00
Belk – 7% rebate
Price: $25.00
Claire's – 9% rebate
Price: $10.00
CVS Pharmacy – 6% rebate
Price: $25.00
CVS Pharmacy – 6% rebate
Price: $100.00
GAP/Old Navy/Banana Republic – 9% rebate
Price: $25.00
Greenleaf Landscape – 10% rebate
Price: $25.00
Home Depot – 4% rebate
Price: $25.00
iTunes – 7% rebate
Price: $15.00
JCPenny – 5% rebate
Price: $25.00
JoAnn Fabrics – 6% rebate
Price: $25.00
K-Mart – 4% rebate
Price: $25.00
K-Mart – 4% rebate
Price: $50.00
Kohl's Department Store – 4% rebate
Price: $25.00
Lands' End – 16% rebate
Price: $25.00
Lowe's – 4% rebate
Price: $25.00
Lowe's – 4% rebate
Price: $100.00
Payless Shoes – 13% rebate
Price: $20.00
Pier I Imports – 9% rebate
Price: $25.00
Rite Aid – 4% rebate
Price: $25.00
Sandy's Florist – 10% rebate
Price: $10.00
Talbot's – 13% rebate
Price: $25.00
Teri Ann's – 10% rebate
Price: $0.00
Any price (write amount in provided field)
Teri Ann's Amount
T-J Maxx – 7% rebate
Price: $25.00
Walmart – 2% rebate
Price: $25.00
Walmart – 2% rebate
Price: $100.00
Walmart – 2% rebate
Price: $250.00
Walgreen's – 6% rebate
Price: $25.00
Walgreen's – 6% rebate
Price: $100.00
Williams-Sonoma/Pottery Barn – 8% rebate
Price: $25.00
Scrip Gift Certificate – 5% rebate
Price: $0.00
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*