CORNERSTONE SCRIP ORDER FORM

Family Name:

Date:

STORE

AMOUNT

%

Quantity

Total Amount

Afterthoughts (Claire's)

$10

9%

Amazon.com

$25

7%

AMC Theatres

$25

7%

American Airlines

$50

16%

American Eagle Outfitters

$25

8%

Andersons

$25

4%

Applebee's

$20

8%

Arby's

$5

10%

B. Dalton Books (Barnes & Noble)

$10/$25

9%

Babies-R-Us (Toys-R-Us)

$20

3%

Bahama Breeze (Red Lobster)

$25

9%

Banana Republic

$25

9%

Barnes & Noble Bookstores

$10/$25

9%

Baskin Robbins

$2

9%

Bass Pro Shops

$25

7%

Bath & Body Works

$10/$25

13%

Beall's

$25

9%

Bed Bath & Beyond

$25

7%

Belk Department Store

$25

7%

Bennigan's

$25

9%

Best Buy

$25/$100

2%

Best Cuts (Regis)

$25

8%

Best Western Int'l

$25

12%

Blockbuster Gift Card

$10

7%

Blockbuster Night Card

$11.50

15%

Blockbuster Single Game Rental

$6

15%

Blockbuster Single Video Rental

$3.79

15%

Bloomingdale's

$25

7%

Bob Evans

$5

10%

Bonefish Grill (Outback)

$25

4%

Borders (Waldenbooks)

$10/$25

8%

Boston Market

$10

12%

Build-A-Bear Workshop

$25

8%

Burdines

$25

12%

Burger King

$5

4%

Cabela's

$25

11%

California Pizza Kitchen

$10

4%

Camera Shop (Ritz Camera)

$25

6%

Carnival Cruises

$100

8%

Carrabba's Italian Grill (Outback)

$25

4%

Casual Corner

$25

19%

ChemLawn (ServiceMaster)

$50

10%

Chili's

$20

11%

Chuck E. Cheese

$10

8%

Circuit City

$50/$100

3%

Citgo

$50/$100

2%

Claire's

$10

9%

Courtyard (Marriott)

$25/$100

12%

Cracker Barrel

$10

9%

Crate and Barrel

$25/$100

8%

CVS Pharmacy

$25

2%

Darden (Red Lobster)

$25

9%

Dave & Busters

$25

8%

Denny's

$5

9%

Dillard's

$25

9%

Domino's Pizza

$5

5%

Eddie Bauer

$25

14%

Express

$25

13%

Express for Men (Express)

$25

13%

Exxon

$50

1.50%

Fairfield Inn (Marriott)

$25/$100

12%

Family Express

$25/$100

4%

Fleming's (Outback)

$25

4%

Footlocker Stores/Lady Footlocker/Kid's Footlocker

$10

9%

Gap/Gap Kids/Baby Gap

$25

9%

GNC

$25

8%

Hollywood Video

$10

15%

Home Depot

$25/$100/500

3%

Honey Baked Ham

$10

9%

Houlihan's

$10

9%

Hyatt Hotels

$25

9%

JCPenney

$25/$100

5%

Jo Ann Fabrics

$20

6%

K Mart

$25/$50

2%

KB Toys

$10

9%

KFC

$5

9%

Kids-R-Us (Toys-R-Us)

$20

3%

Landry's Seafood Restaurants

$25

9%

Lillian Vernon

$15

17%

Limited

$25

9%

Linens 'n Things

$25

8%

Long John Silver's

$5

9%

Longhorn Steakhouse

$25

11%

Lowe's Home Improvement

$25/$100

4%

Macaroni Grill (Chili's)

$20

11%

Macy's

$25/$100

9%

Maggiano's Little Italy (Chilli's)

$20

11%

Marathon Gas

$25/$100

3%

Marriott Hotels

$25/$100

12%

Marshalls (TJ Maxx)

$10/$25

7%

MasterCuts (Regis Salons)

$25

8%

Men's Wearhouse

$25

7%

Mia & Maxx Hair Studio (Regis)

$25

8%

Mobil (Exxon)

$50

1.50%

Mrs. Field's Cookies

5$

25%

O'Charley's

$25

13%

Office Depot

$25

4%

Office Max

$25

5%

Old Navy

$25

9%

Outback Steakhouse

$25

4%

Panera Bread

$10

9%

Payless Shoes

$20

13%

Pep Boys

$20

4%

Pier 1 Imports

$25

9%

Pizza Hut

$10

9%

Pottery Barn/PB Teen/ Pottery Barn for Kids (Williams Sonoma)

$25

8%

Pretzel Time

$10

25%

Rainforest Café (Landry's)

$25

9%

Red Lobster

$25

9%

Regis Salons

$25

8%

Renaissance (Marriott)

$25/$100

12%

Residence Inn (Marriott)

$25/$100

12%

Restoration Hardware

$25

12%

Ritz Camera

$25

6%

Ruby Tuesday’s

$25

8%

Sam Goody

$10

9%

Sears

$25/$100/250

4%

ServiceMaster

$50

10%

Sharper Image

$50

12%

Shell Gas

$25/$100

2%

Shoe Carnival

$25

5%

Spaghetti Warehouse

$20

18%

Sports Authority

$25

8%

Staples

$25

5%

Starbucks

$10/$25

7%

Steak and Ale (Bennigan's)

$25

9%

Structure (Express)

$25

13%

Sunglass Hut

$25

10%

Super Cuts (Regis)

$25

8%

Sweet Tomatoes

$10

8%

T.J. Maxx

$10/$25

7%

TCBY

$5

25%

Terminix (ServiceMaster)

$50

10%

TGI Friday's

$20

8%

The Children's Place

$25

12%

Tobacco Outlet Plus (Kwik Trip)

$20

3%

Tony Roma's

$20

9%

Toys-R-Us

$20

3%

Trade Secret (Regis Salons)

$25

8%

TruGreen (Servicemaster)

$50

10%

Union 76

$25

2.50%

Uno's Chicago Grill

$25

17%

Valvoline Instant Oil Change

$27.99

17%

Waldenbooks

$10/$25

8%

Walgreens

$20

2%

Watch World (Sunglass Hut)

$25

10%

Wendy's

$10

9%

Winn Dixie

$25/$50

4%

Wolf Camera (Ritz Camera)

$25

6%