Saint Dorothy – Dot’s Dollars Program Date______Total # of Cards ______Cash ______

Name ______Phone # ______Total Amount $______Check # ______

Address ______

Please make check payable to Saint Dorothy H & S

Stores / Amount / Discount / # of cards / Dollar Amount / Stores / Amount / Discount / # of cards / Dollar Amount
Acme / $25 / 3% / ShopRite / $25 / 3%
Acme / $100 / 3% / ShopRite / $100 / 3%
Amazon.com / $25 / 2.25% / Staples / $25 / 3.75%
Amazon.com / $100 / 2.25% / The Children's Place / $25 / 9%
American Girl Doll / $25 / 6.75% / Target / $25 / 1.875%
Barnes & Noble Bookstores / $10 / 6.75% / TJ Maxx/ Home Goods/ Marshalls / $25 / 5.25%
Bath & Body Works / $10 / 9.75% / Toys/Kids/Babies-R-Us / 20 / 2.25%
Bed, Bath & Beyond / $25 / 5.25% / Wal-Mart / $25 / 1.875%
Claire's / $10 / 6.75% / Wawa / $25 / 1.125%
CVS / $25 / 4.5% / Arby’s / $10 / 6%
Dick's Sporting Goods / $25 / 6% / Chipotle Mexican Grill / $10 / 7.5%
Game Stop/ EB Games / $25 / 2.25% / Dairy Queen / $10 / 2.25%
Gap Tri-Card(Banana Republic, Old Navy, & Gap) / $25 / 10.5% / Dominos / $10 / 6%
Giant Foods / $25 / 3% / Dunkin Donuts / $10 / 2.25%
Giant Foods / $50 / 3% / Panera Bread / $10 / 6.75%
Giant Foods / $100 / 3% / Perfect Circle / $10 / 37.5%
Great Clips / $25 / 6% / Pizza Hut / $10 / 6%
Home Depot / $25 / 3% / Outback/Bonefish / $25 / 6%
ITunes / $15 / 3.75% / Qdoba / $25 / 5.25%
Jo-Ann Fabric Stores / $25 / 4.5% / Quiznos / $10 / 3%
Kohl's / $10 / 3.75% / Rita's / $5 / 7.5%
Kohl’s / $25 / 3.75% / Starbucks / $10 / 5.25%
Kohl’s / $50 / 3.75% / Subway / $10 / 4.5%
Kohl’s / $100 / 3% / Swiss Farms / $25 / 3.75%
L.L.Bean / $25 / 12% / Tony Roni's / $10 / 7.5%
Lands’ End / $25 / 12% / Wendy's / $10 / 3%
Lowes Home Improvement / $25 / 3% / AMC Theaters / $25 / 6%
Payless / $20 / 9.75% / AMC Single Ticket / $9.50 / 7.5%
Rite Aid / $25 / 3% / Regal Single Ticket / $10 / 7.5%
Ross / $25 / 6%
Column 1 TOTAL / Column 2 TOTAL
GRAND TOTAL