ABCDEFGHIJKLMNOPQRSTUVWXYZ
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Date: ___________ Last Name: __________________________ Scrip Account #: _____
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Store NameDenominationQuantityTotal
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Amazon (1.5%)$25
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$100
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Arco (1.5%)$50
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Chevron (1%)$50
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Classic Design (10%)$100
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Devil's Teeth (10%)$25
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Gap/Old Navy/Banana Republic (14%)$100
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Guerra's Meats (8%)$50
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Gus’s Market (6%)$100
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Home Depot (4%)$100
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Home Coffee Roasters (10%) $25
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Java Beach (10%)$25
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Lucky/Save Mart (2%)$25
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$100
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Macy's (10%) $25
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$100
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Nordstrom (4%)$25
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$100
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Ross (8%)$25
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Safeway (4%)$25
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$100
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Shell (1.5%)$100
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Starbucks (4.5%)$10
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$25
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Target (2.5%)$25
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$100
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UNOCAL 76 (1.5%)$100
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Walgreens (5%)$25
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$100
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Grand Total:$0.00
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Advance payment is necessary when ordering through the school envelope. Orders are delivered to students on
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Thursdays. Please make checks payable to SGPO. Payment must be included with pre-order from.
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Please allow my child, ___________________________, to bring my SCRIP home in a specially marked envelope.
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Scrip Purchase Goal
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To ensure that your family receives credit towards your SCRIP purchase goal, indicate family
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name and SCRIP account # below. Please be sure that if extended family members purchase SCRIP, they
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also indicate your family name and account #.
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I understand that SCRIP is like cash and that the SGPO is not responsible
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if it is lost or stolen. I also understand that SCRIP purchases are not tax deductible.
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Signature: ________________________________________________________
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