| Northside Methodist Academy Scrip Order Form | ||||||||||
| Orders due on Tuesday by 9:00am. Orders will be delivered by Friday. | ||||||||||
| ***** Full payment must accompany order. ***** Make checks payable to N.M.A. Scrip ***** | ||||||||||
| Your Name:____________________________________________Telephone #:__________________________ | ||||||||||
| Child's Name:__________________________________________Grade/Homeroom:______________________ | ||||||||||
| Merchant | Amount $ | % | QTY | Total $ | Merchant | Amount $ | % | QTY | Total $ | |
| Belks | $25.00 | 7.0% | ||||||||
| GAS STATION | Best Buy | $25.00 | 2.0% | |||||||
| Shell Gas | $25.00 | 1.5% | Carrolls Nursery | $20.00 | 10.0% | |||||
| Shell Gas | $100.00 | 1.5% | CVS Pharmacy | $25.00 | 2.0% | |||||
| Chevron | $50.00 | 1.5% | Dick's Sporting Goods | $25.00 | 5.0% | |||||
| BP Gas Station | $50.00 | 2.0% | Dillard's | $25.00 | 9.0% | |||||
| Express | $25.00 | 13.0% | ||||||||
| GROCERY | Family Christian Stores | $25.00 | 9.0% | |||||||
| Winn Dixie Grocery | $25.00 | 4.0% | Flowers by Mary Ann | $25.00 | 20.0% | |||||
| Winn Dixie Grocery | $100.00 | 4.0% | Flowers by Mary Ann | $50.00 | 20.0% | |||||
| Footlocker Stores | $25.00 | 9.0% | ||||||||
| RESTAURANTS | Gap/Banana/Old Navy | $25.00 | 9.0% | |||||||
| Applebee's | $25.00 | 8.0% | Gymboree | $25.0 | 13.0% | |||||
| Arby's | $10.00 | 10.0% | Home Depot | $25.00 | 3.0% | |||||
| Burger King | $10.00 | 4.0% | Home Depot | $100.00 | 3.0% | |||||
| Chili's | $25.00 | 11.0% | JCPenney | $25.00 | 5.0% | |||||
| Conestoga | $25.00 | 10.0% | JCPenney | $100.00 | 5.0% | |||||
| Cracker Barrel | $10.00 | 9.0% | K Mart | $25.00 | 4.0% | |||||
| Domino's Pizza | $5.00 | 5.0% | KB Toys | $20.00 | 9.0% | |||||
| Kohl's | $25.00 | 4.0% | ||||||||
| Honey Baked Ham | $10.00 | 12.0% | Lowe's Home Improv. | $25.00 | 4.0% | |||||
| KFC | $5.00 | 9.0% | Lowe's Home Improv. | $100.00 | 4.0% | |||||
| Logan's Roadhouse | $25.00 | 8.0% | Marriott | $50.00 | 12.0% | |||||
| Long John Silver's | $5.00 | 9.0% | Mary Kay -Donna Brackin | $20.00 | 20.0% | |||||
| O'Charley's | $25.00 | 13.0% | Michael's | $25.00 | 4.0% | |||||
| Papa Johns Pizza | $10.00 | 6.0% | Office Depot | $25.00 | 4.0% | |||||
| Old Mill | $20.00 | 10.0% | Office Max | $25.00 | 5.0% | |||||
| Outback Steakhouse | $25.00 | 4.0% | Payless Shoes | $20.00 | 13.0% | |||||
| Pizza Hut | $10.00 | 9.0% | Pet Smart | $25.00 | 4% | |||||
| Red Lobster/Olive Garden/Longhorn | $25.00 | 9.0% | Pier 1 Imports | $25.00 | 9.0% | |||||
| Ruby Tuesdays | $25.00 | 8.0% | Radio Shack | $25.00 | 4.0% | |||||
| Wendy's | $10.00 | 4.0% | Ross Dress for Less | $25.00 | 8.0% | |||||
| TGI Fridays | $25.00 | 8.0% | Sears | $25.00 | 4.0% | |||||
| Ryans Steakhouse | $25.00 | 7.0% | Shoe Carnival | $25.00 | 5.0% | |||||
| T.J. Maxx | $25.00 | 7.0% | ||||||||
| Toys-R-Us (Kids-R-Us) | $20.00 | 1.5% | ||||||||
| RETAIL | Walgreens | $20.00 | 2.0% | |||||||
| Wal-Mart | $25.00 | 2.0% | ||||||||
| Advance Auto Parts | $25.00 | 7.0% | Wal-Mart | $100.00 | 2.0% | |||||
| American Eagle Outfitters | $25.00 | 9.0% | ||||||||
| Barnes & Noble | $25.00 | 9.0% | ||||||||
| Bath & Body Works | $10.00 | 13.0% | ||||||||
| TOTAL: | $ | |||||||||