EHCA Scrip Order Form Payment & Forms Due on MONDAYS by 9 a.m.

Revised 1/23/06

Name: Date:            _     

Pick Up Person:________________Grade?_________

Account #: Check #(s): Total: Phone:___________________

	Retailer	Amount	Credit	Qty	Cost		Retailer	Amount	Credit	Qty	Cost
1	Ace Hardware	$25	4%			34	LL Bean	$25	15%
2	Amazon.com	$25	4%			35	Rite Aid	$25	4%
3	American Eagle	$25	8%			36	Sears	$25	4%
4	Barnes & Noble	$10	9%			37	Staples	$25	5%
5a	Bath & Body	$10	13%			38	Childrens Place	$25	12%
5b	Bath & Body	$25	13%			39	ToysRUs	$20	3%
6	Bed,Bath,Bey	$25	7%				RESTAURANTS	More @	glscrip.com
7a	BlockBuster	$10	7%			40	Applebee’s	$20	8%
8	BonTon/EB	$25	9%			41	Arby’s	$5	10%
9	Borders/Waldenbk	$10	8%			42	Bob Evans	$10	10%
10	Boscov’s	$25	5%			43	Chuck E Cheese	$10	8%
11	Cabela’s	$25	11%			44	Cracker Barrel	$10	9%
12	Cinamark	$25	4%			45	Denny’s	$5	9%
13	Claire’s	$10	9%			46a	Eat N Park	$5	10%
14	Community Mkt	$25	4%			46b	Eat N Park	$10	10%
15	CVS Pharmacy	$25	2%			47	KFC	$5	9%
16	Dick’s Sports	$25	8%			48	Long Johns	$5	9%
17	Family Christian	$10	9%			49	Longhorn Steakhs	$25	11%
18	Friedman’s/BiLo	$10	4%			50	Max & Erma’s	$20	13%
19	Gander Mtn	$25	8%			51	Olive Gdn/Red Lbst	$25	9%
20a	G. Eagle/GetGo	$25	4%			52	Outback Steak	$25	4%
20b	G. Eagle/GetGo	$100	4%			53	Panera Bread	$10	9%