GROCERY

%

Value

Quantity

Total $

BRESELOW’S

FAMILY MARKET

3%

$10

$25

$50

GLENN’S MARKET

5%

$10

KRAEMER WIS. CHEESE

10%

$10

PICK ‘N SAVE          

4%

$25

$100

PIGGLY WIGGLY    

3%

$25

$50

$100

RESTAURANT/FOOD

%

Val.

Qty

Ttl $

APPLEBEE’S

8%

$25

ARBY’S

8%

$10

BURGER KING

4%

$10

CHILI’S

11%

$25

COUSIN’S SUBS

9%

$10

CRACKER BARREL

9%

$10

CULVER’S

10%

$5

DOMINO’S PIZZA

8%

$10

KENTUCKY FRIED   CHICKEN

9%

$5

OLIVE GARDEN/ RED LOBSTER

9%

$25

OUTBACK STEAKHOUSE

5%

$25

PAPA MURPHY’S

8%

$10

PIZZA HUT-Advise Card Paymnt

8%

$10

STEAKFIRE

10%

$10

$25

$50

SUBWAY

3%

$10

TEXAS ROADHOUSE

8%

$25

TGI FRIDAYS

8%

$20

DEPARTMENT

%

Value

Quantity

Total $

DRESS BARN

8%

$25

GANDER MOUNTAIN

8%

$25

KOHL’S DEPT.  

5%

$10

$25

$50

$100

OLD NAVY/THE GAP

“OPTIONS CARD”

9%

$25

JC PENNEY

5%

$25        

SEARS                

4%

$25

$100

SHOPKO              

4%

$25

$50

TARGET

4%

$25

$100

T-J MAXX MARSHALL’S

7%

$10

$25

WAL-MART/

SAM’S CLUB

2%

$25

$100

SPECIALTY STORE

%

Value

Quantity

Total $

ACE HARDWARE.

5%

$10

$25

BARNES & NOBLE

9%

$10

$25

WATERTOWN BOOK SELLERS

9%

$10

$25

BATH & BODY WKS

13%

$10

$25

BEST BUY

2%

$25

$100

CABELLA’S

11%

$25

DAVID’S PAINTS

(**SPECIAL ORDER)

5%

Order

$ Amt.

Needed

FARM & FLEET  

5%

$20

$25

$50

$100

HOME DEPOT

3%

$25

$100

JOANN FABRICS

6%

$20

MENARDS

3%

$25

$100

WALGREEN’S

6%

$25

TRAVEL

%

Value

Quantity

Total $

BORDERLINE BP

10%

$25

KWIK TRIP    

4%

$10

$20

$25

$50

$100

SPEEDWAY/  

SUPERAMERICA

4%

$25

$100

TOTAL SIDE 1

           $

TOTAL SIDE 2

           $

GRAND TOTAL:

           $

MAKE CHECKS

PAYABLE TO:

ST HENRY SCRIP

CHECK #

CASH:

DATE DELIVERED