Address: Phone #
Place my order as One Time Order Standing Order – Weekly, Bi-Weekly or Monthly (Circle one)
Delivery Method (circle one)-Pick up / Send with Student/ Mail ______-
Questions? Contact Chris Doherty 815-399-8850 ext. 133 or
% / Local Merchants / Cost / QTY. / Total / % / National Merchants / Cost / QTY / Total
8% / AMC / $10/25 / Restaurants
10% / Backyard Grill / $25 / 8% / Applebee’s / $25/$50
5% / Beef A Roo / $10 / 8% / Arby’s / $10
10% / Crimson Ridge / $10/25/50 / 8% / Buffalo Wild Wings / $25
10% / Culver’s / $10 / 4% / Burger King / $10
6% / Great Harvest Bread / $10 / 9% / Chili’s Grill & Bar / $25
10% / Lino’s / $25 / 10% / Chipotle Grill / $10
8% / Mary’s Market / $25 / 8% / Cold Stone Creamery / $10
5% / Meg’s Daily Grind / $10 / 9% / Cracker Barrel / $10/$25
3% / Meijer / $25/50/100 / 3% / Dairy Queen / $10
8% / Panda Express / $25 / 8% / Domino’s Pizza / $10
8% / Pizza Ranch / $25 / 3% / Dunkin Donuts / $10
5% / Postal Shoppe (except stamps) / $25 / 8% / KFC / $5
10% / Rathskellar / $10 / 12% / Lettuce Entertain You / $25
2.5% / Road Ranger / $50/$100 / 8% / Little Caesar’s / $20
10% / Shogun Japanese / $20 / 11% / Maggiano's Little Italy / $25
5% / Woodmans / $50/$100 / 8% / Noodle’s & Company / $10
6% / Old Chicago / $25
8% / Six Flags Great America / $42.25 / 9% / Olive Garden/Red Lobster / $25
8% / Outback / $25/$50
8% / P.F. Chang’s / $25
9% / Panera Bread / $10/$25
8% / Papa John’s Pizza / $10
8% / Pizza Hut / $10
7% / Qdoba Mexican Grill / $25
11% / Red Robin / $25
National Merchants / 8% / Ruby Tuesday / $25
8% / Avis Car Rental / $50 / 7% / Starbucks / $10/$25
10% / BedandBreakfast.com / $50 / 8% / Steak & Shake / $10
12% / Best Western International / $25/$100 / 3% / Subway / $10/$50
8% / Budget Rent a Car / $50 / 3% / Taco Bell / $10
8% / Carnival Cruises / $100 / 8% / Texas Roadhouse / $25
8% / Fairfield Inn / $50/$100 / 9% / T.G.I. Friday’s / $25
9% / Hyatt Hotels / $50/$100 / 4% / Wendys / $10
4% / Mainstay Suites / $50/$100 / 3% / Whole Foods / $25
8% / Marriot Hotels / $50/$100
4% / Quality Inn / $50/$100
8% / Ritz Carlson Hotel Company / $50
Column #1 Total Column #2 Total
Scrip Order Form% / National Merchants / Cost / QTY. / Total / % / National Merchants / Cost / QTY. / Total
4% / Ace Hardware / $25/$100 / 4% / Kohl’s / $25/$100
7% / Aeropostale / $25 / 15% / L.L. Bean / $25/$100
7% / A.J. Wright / $25/$100 / 16% / Land’s End / $25/$100
4% / Albertson’s/Jewel / $25/$100 / 9% / Limited, The / $25
4% / Amazon.com / $25/$100 / 8% / Lord & Taylor / $25
10% / American Eagle Outfitters / $25 / 4% / Lowe’s Home Imp. / 25/100/500
8% / Auto Zone / $25 / 10% / Macy’s / $25/$100
9% / Barnes & Noble / $10/25/100 / 3% / Marathon Gas / $25/$100
13% / Bath & Body Works / $10/$25 / 7% / Marshall’s / $25/$100
7% / Bed Bath & Beyond / $25/$100 / 8% / MC Sports / $25
8% / Bergner’s/Younkers / $25/$100 / 3% / Menard’s / $25/ $100
3% / Best Buy / $25/100/250 / 4% / Michael’s / $25
12% / Bloomingdales / $25/$100 / 12% / Neiman Marcus / $50
1.5% / BP Gas / $50/100/250 / 12% / Nike / $25
8% / Build A Bear Workshop / $25 / 4% / Office Depot / $25/$100
8% / Burlington Coat Factory / $25 / 5% / Office Max / $25/$100
11% / Cabela’s / $25/$100 / 14% / Old Navy / $25
12% / Children’s Place / $25 / 11% / Omaha Steaks / $25
9% / Claire’s / $10 / 13% / Payless Shoes / $20
9% / Container Store / $25/$100 / 4% / PetSmart / $25
8% / Crate & Barrel / $25/$100 / 9% / Pier 1 Imports / $25
6% / CVS Pharmacy / $25/$100 / 8% / Pottery Barn / $25/$100
13% / Dave & Buster’s / $25 / 8% / REI Sporting Goods / $25
4% / Dell Computer / $100 / 12% / Sally Beauty Supply / $25
8% / Dick’s Sporting Goods / $25 / 2% / Sam’s Club / $25/$100
4% / Dominick’s/Safeway / $25/$100 / 6% / Sear’s / $25/$100
10% / Eddie Bauer / $25 / 4% / Sephora / $20
1% / Exxon/Mobil / $50/$250 / 2.5% / Shell Gas / $25/50/100
25% / Fannie Mae Candies / $10 / 5% / Shoe Carnival / $25
10% / Finish Line / $25 / 3% / Shopko / $25/$100
9% / Foot Locker / $25 / 4% / Speedway / $25/$100
3% / GameStop / $25 / 11% / Sports Authority / $25/$100
8% / Gander Mountain / $25 / 5% / Staples / $25/$100
9% / Gap/Old Navy / $25 / 12% / Sunglass Hut / $25
4% / GFS Marketplace / $25/$100 / 13% / Talbots / $25
7% / Gordmans / $25 / 2.5% / Target / $25/$100
13% / Gymboree / $25 / 3% / Toys R Us / $20/50/100
4% / Hallmark Gold Crown / $25 / 7% / TJ Maxx / $25/$100
10% / Harry & David / $25 / 4% / Ulta Salon / $25
7% / HomeGoods / $25/$100 / 2% / Wal-mart/Sam’s Club / 25/100/250
6% / Home Shopping Network / $25 / 6% / Walgreens / $25/$100
5% / iTunes / $15/$25 / 8% / Williams-Sonoma / $25/$100
13% / J. Crew / $25 / 8% / Zappos.com / $25
8% / J. Jill / $25
5% / J.C. Penny / $25/$100
8% / Jiffy Lube / $30
6% / Jo Ann Fabrics / $25
6% / Kay Jewelers / $50
6% / K-Mart / $25/$50
Column #3 Total Column #4 Total