KWIK SCRIP ORDER FORM – MOSS Scrip Gift Cards

Order filled by: Date: Order entered by: Date: Order #

ORDER INFORMATION (Fill out completely)

Name: Today’s Date: Last First

Tuition Credit (Family Name): Check number: # Daytime Phone: Order Total: $

Email: Tuition Credit: $

Send Home: No Substitutions please* Name (Student) Teacher/ Grade (check if you prefer exact denominations – this may cause a delay in filling your order*)

Make checks payable to “Mother of Sorrows School”

RETAILER AVAILABILITY AND % DISCOUNTS ARE SUBJECT TO CHANGE AT ANY TIME WITHOUT NOTICE Revised 03-15-16

Discount School Families Retailer Amount QTY Total % $ @ 75% Credit Barnes & Noble $10.00 $0.00 9% $0.90 $0.68 $0.00 Bath and Body Works $10.00 $0.00 13% $1.30 $0.98 $0.00 Bob Evans $10.00 $0.00 10% $1.00 $0.75 $0.00 Dairy Queen $10.00 3% $0.30 $0.23 Dunkin' Donuts $10.00 $0.00 3% $0.30 $0.23 $0.00 Eat 'N Park $10.00 $0.00 10% $1.00 $0.75 $0.00 Eat 'N Park $25.00 $0.00 10% $2.50 $1.88 $0.00 Giant Eagle (can use w/ your Giant Eagle $25.00 $0.00 5% $1.25 $0.94 $0.00 Giant Eagle Advantage Card® and $50.00 $0.00 5% $2.50 $1.88 $0.00 Giant Eagle receive Fuelperks® on $100.00 $0.00 5% $5.00 $3.75 $0.00 Giant Eagle groceries & gift cards, plus $200.00 $0.00 5% $10.00 $7.50 $0.00 Giant Eagle Foodperks® on GetGo® Fuel) $500.00 $0.00 5% $25.00 $18.75 $0.00 Kohl's (can pay on charge) $25.00 $0.00 5% $1.25 $0.94 $0.00 Kohl's (can pay on charge) $50.00 $0.00 5% $2.50 $1.88 $0.00 Kohl's (can pay on charge) $100.00 $0.00 5% $5.00 $3.75 $0.00 Lowe’s $25.00 4% $1.00 $0.75 Lowe’s $100.00 4% $4.00 $3.00 Lowe’s $500.00 4% $20.00 $15.00 Panera Bread $10.00 $0.00 9% $0.90 $0.68 $0.00 Panera Bread $25.00 $0.00 9% $2.25 $1.69 $0.00 Rite Aid $25.00 4% $1.00 $0.75 Sheetz $25.00 $0.00 3% $0.75 $0.56 $0.00 Sheetz $100.00 $0.00 3% $3.00 $2.25 $0.00 Shop 'N Save $25.00 $0.00 5% $1.25 $0.94 $0.00 Shop 'N Save $50.00 $0.00 5% $2.50 $1.88 $0.00 Shop 'N Save $100.00 $0.00 5% $5.00 $3.75 $0.00 SportClips Adult MVP ( a $24 Value) $20.00 25% $5.00 $3.75 SportClips Child/SeniorMVP(an $18 Value) $15.00 20% $3.00 $2.25 Starbucks $10.00 7% $0.70 $0.53 Sunoco $50.00 $0.00 1% $0.50 $0.35 $0.00 Walgreens $25.00 6% $1.50 $1.13 Wal-Mart / Sam's Club $25.00 $0.00 2.5% $0.50 $0.38 $0.00 Wal-Mart / Sam's Club $100.00 $0.00 2.5% $2.00 $1.50 $0.00 Wal-Mart / Sam's Club $250.00 $0.00 2.5% $6.25 $4.69 $0.00 Wendy's $10.00 $0.00 4% $0.40 $0.30 $0.00 TOTALS: