EHCA PRE-BOUGHT Scrip Order Form

Name:                                                    ___ Date: Account :___________ __     

Check #(s): Total: Phone:__         _______________      __

	Retailer	Amt	Credit	Qty	Cost		Retailer	Amt	Credit	Qty	Cost
1	Community Mkt	$25	4%				RESTAURANTS:
2	Family Christian	$10	9%			9	Arby’s	$5	10%
3	G Eagle/GetGo	$25	4%			10	Cracker Barrel	$10	9%
4	JC Penney	$25	5%			11	Dardens:  Olive Grdn Red Lbster/Smky Bn	$25	9%
5	JoAnn Fabric	$20	6%			12	Eat N Park	$5	10%
6	Mulone Theater (S Pike & Cheswick Theaters)	$5	20%			13	Eat N Park	$10	10%
7	Sears	$25	4%			14	KFC	$5	9%
8	Sheetz	$25	3%			15	Max & Ermas	$20	13%
						16	Panera Bread	$10	9%
						17	Pizza Hut	$10	9%
						18	Subway	$3.50	30%
						19	Wendy’s	$10	9%
						20	Vocelli’s-lg 1 tpg pizza	$8	50%
						21	Vocelli’s-9 coupons	$10	50%

Signature of person receiving this order___________________________________

Date rec’d______________________                                                Updated 12/19/05