Providence Academy Scrip Order Form

Providence Academy Scrip Order Form Name: _____________________________________ Scrip Amazon Amazon Cabelas Dominos Family Restaurant Festival Foods Festival Foods Gander Mountain iTunes Kohl's Kohl's Kwik Trip Kwik Trip Kwik Trip Marcus Theater Menards Menards Moka Moka Olive Garden Panera Shopko Shopko Starbucks Starbucks Subway SWEET SHOP Walgreens Wal-mart/Sams Club Wal-mart/Sams Club Woodmans Woodmans

Increments Available $25.00 $100.00 $25.00 $10.00 $10.00 $50.00 $100.00 $25.00 $15.00 $25.00 $100.00 $25.00 $50.00 $100.00 $25.00 $25.00 $100.00 $10.00 $25.00 $25.00 $10.00 $25.00 $100.00 $10.00 $25.00 $10.00 $5.00 $25.00 $25.00 $100.00 $50.00 $100.00

% Donated # Desired 3.0% 3.0% 11.0% 8.0% 10.0% 4.0% 4.0% 8.0% 5.0% 4.0% 4.0% 5.0% 5.0% 5.0% 9.0% 3.0% 3.0% 7.0% 7.0% 9.0% 9.0% 3.0% 3.0% 7.0% 7.0% 6.0% 15.0% 6.0% 2.5% 2.5% 5.0% 5.0%

Total Due

Date: _______________ Check #: _____________

TOTAL AMOUNT DUE: Make checks payable to Providence Academy Scrip Scrip 9/15/2016