Vender Name

%

Scrip $

Quan

Total

Vender Name

%

Scrip $

Quan

Total

Grocery Stores

Limited

9%

$25

Shop N Save

5%

$25/100

Lowes Home Improvement

4%

$25/100

Walmart/Sams

2%

$25/100

Lowes Home Improvement

4%

$500/1000

RETAILERS

Macy’s

10%

$25/100

Advance Auto Parts

7%

$25

Michaels

4%

$25

AMC Theatres

7%

$25

Office Depot

4%

$25/100

American Eagle Outfitters

9%

$25

Office Max

5%

$25

American Express

1.25%

$100/200

Old Navy/Gap/Piperlime

9%

$25

AT&T 125min card

20%

$9.50

Payless Shoes

13%

$20

Barnes and Nobles

9%

$10/20/25

Petsmart

4%

$25

Bass Pro Shops

9%

$25/100

Pottery Barn (Williams-Sonoma

8%

$25/100

Bed, Bath & Beyond

7%

$25

REI Sporting Goods

8%

$25

Best Buy

3%

$25/100/250

Sports Authority

8%

$25/100

Blockbuster

7%

$10

Supercuts

8%

$25

Borders

9%

$10/25

Talbots

13%

$25

Cabela’s

11%

$25/100

Tanger Outlets

8%

$25

Claire’s

9%

$10

Toys-R-Us

1.50%

$20

Crate and Barrel

8%

$25/100

TJ Maxx/Marshalls/Home Goods

7%

$25/100

Dick’s Sporting Goods

8%

$25

The Children’s Place

12%

$25

Dillards

9%

$25/100

VISA Rewards Card

2%

$25/50/100

Disney

2%

$25/100/1000

Walgreens

6%

$25/100

Dressbarn

8%

$25

Express Clothing

10%

$25

Family Christian Stores

9%

$25

Family Video

12%

$10

TRAVEL

Fashion Bug

8%

$25

American Airlines

8%

$100/250

Game Stop

3%

$25

Best Western

12%

$25/100

GNC

8%

$25

Carnival Cruises

8%

$100

Gordman’s

7%

$25

Clarion Hotels

6%

$25/100

Great Clips

8%

$25

Hyatt Hotels

9%

$50/100

Gymboree

13%

$25

Marriott Hotel Chain

8%

$50/100/500

JC Penny

7%

$25/100

Avis Car Rental

8%

$50

Jo Ann Fabrics

6%

$20

Budget Car Rental

8%

$50

Kmart

4%

$25/50

Kohl’s

4%

$25/100

                         TOTAL FRONT PAGE: $______________

Lands’End

17%

$25/100

Vender Name

%

Scrip $

Total

Vender Name

%

Scrip $

Quan

Total

RESTAURANTS

GAS/OIL

Applebee’s

8%

$25/50

BP

2%

$50/100/250

Arby’s

8%

$10

Exxon/ Mobil

1.50%

$50/100

Baskin Robbins

9%

$2

Shell

2.50%

$25/50/100

Bob Evans

10%

$10

Jiffy Lube

8%

$30

Burger King

4%

$10

California Pizza Kitchen

4%

$10

Cheesecake Factory

5%

$25

Internet Stores

Chipotle Mexican

10%

$10

Amazon.com

4%

$25/100

Chevy’s Fresh Mex

8%

$25

Fannie May Candies

25%

$10

Chili’s

11%

$25

I-tunes

4%

$15

Chuck E Cheese

8%

$10

Shutterfly.com

9%

$25

Cold Stone Creamery

8%

$10

Cracker Barrel

9%

$10

Dave and Busters

13%

$25

Denny’s

7%

$10

Other Merchants

Domino’s Pizza

5%

$5

1-800-Flowers

25%

$10

Domino’s Pizza/2 Liter

25%

$14

675 Min Total Access Card

15%

$20

Fazoli’s

7%

$25

Scrip Cascading Card File

25%

$2.96

Hometown Buffet

5%

$25

Honey Baked Ham

12%

$10

Jack in the Box

4%

$10

Write In Retailers

www.glscrip.com

KFC

9%

$5

Little Caesar’s Pizza

8%

$20

Landry’s Seafood House

9%

$25

Long John Silver’s

8%

$5

Longhorn Steakhouse

9%

$25

Macaroni Grill

11%

$25

Maggiano’s Little Italy

11%

$25

TOTAL FRONT PAGE: $________________

TOTAL BACK PAGE  :  $________________

ORDER GRAND TOTAL:  $______________

CHECK # ___________

Max and Erma’s