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SMCESS SCRIP ORDER FORM AND INFORMATION Please save the white slips that you receive with your order. Let me know any discrepancies immediately. NEW: DeLullo's new $10 Extreme Ultimate Lustrsashield wash -increases vehicle gloss DeLullo's pizza $8 at 10% DeLullo's deli/gas $10 or $25 at 3% Walmart $250 denomination Pop-in-Video now available Limited amounts of On Hand Inventory now available at the Elementary School. CHANGES: DeLullo's car wash now 15% DELETIONS: Lillian Vernon is no longer available. If you currently have these certificates, they MUST be used immediately. OTHER: Dairy Queen is Back!! Please note that Pfaffs and Bilo grocery certificates are always available at the school offices. Please use the most updated order form. For additional information regarding restrictions or national vendors available, visit the Great Lakes website at www.glscrip.com. If there is something on the national list but not on our order form, add the item to this page of the order form. If you have any SCRIP questions, call Chris Gismondi - 834-4215 THANK YOU! Name________________________________________ Account # ___________________________ If you have not filled out an Information Form, then you do not have an account number and must do so before placing an order. The tuition account credited is based on the Information Form filled out. Certificates are non-returnable, please plan accordingly. Thank you.! . Delivery information: If delivery information is the same as the information on the preprinted labels from your past orders, DO NOT complete the delivery information below I will pick-up/my child will bring home my order from:_______ Elementary _______ Middle Check here if pick-up instructions are different than information on file. ________ Please record your totals below: _________Retail Store _________Other Retail _________Restaurants _________Gas and Groceries _________Travel _________Scrip Wallet or Gift Wrappers _________Purchased Locally _________Purchased Locally Total Due with your order _________ Check Name Check # Amount ___________________________________________________ ___________________________________________________ Cash_______________________________ Updated 3/10/2008