Family Name: ______________________________
Oldest Child's Name:________________________________		(If Applicable)
Oldest Child's Grade:  __________________	(If Applicable)
Phone numbers:  (Day)___________________  (Evening)___________________
DIRECTIONS:
*  Indicate the name of the participating store for which you wish to purchase Scrip.
*  Indicate the denomination, quantity and amount of each store's Scrip.
*  Total your Order and enter at the bottom where indicated.
*  Include a check for the "Total Amount".
*  Payment MUST be included.  **  Return Check Fee is $35.00.**
PARTICIPATING STORE NAME	DENOMINATION	QUANTITY	AMOUNT
Example:  Albertsons	$25.00	2	$50.00
Albertsons	$100.00	4	$400.00
Total Amount
FOR OFFICE USE ONLY:		IMPORTANT
Cash/Check Number: ________________________
Order Filled By: ____________________________	Please indicate whether you want the order
Delivery Date: _____________________________	sent home with your child _____,
Order Received By: _________________________	or if you will pick-up order _____.