Order Form.xlsx
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Scrip Order Form
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Name Phone #: Total:
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Date
SN = ScripNow Item
Amounts in parentheses next to items are also available.
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R = Reload Item
Online look for local items under “Xtra Stuff” or in search box.
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RN = Reload Now
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RebateQtyExt Price RebateQtyExt Price
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Aeropostal $25 (R, SN)10% Famous Footwear $258%
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Amazon.com $25 (SN) ($100)2.25%Fareway $252%
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American Eagle Outfitters $25 (SN)10% Fareway $502%
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Applebee's $25 (SN) ($50)8% Fareway $1002%
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Arby's $108%Fareway $2002%
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Athleta $25 (SN, RN) ($100)14% Gap/Old Navy/Athleta $25 (SN, RN)14%
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Barnes & Noble $10 (SN)8% Gap/Old Navy/Athleta $100 (SN, RN)14%
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Barnes & Noble $25 (SN) ($100)8%Gymboree $25 (R,SN)13%
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Bath & Body Works $10 (SN, R)12% Hardee's $105%
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Bath & Body Works $25 (SN, R)12% (The) Home Depot $25 (SN)4%
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Bed Bath & Beyond $25 ($100)7% (The) Home Depot $100 (SN) ($500, $1,000)4%
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Best Buy $25 (SN) ($100, $250)4% HyVee $255%
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Bomgaars $25 5% HyVee $505%
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Bomgaars $100 5% HyVee $1005%
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Bomgaars $5005% HyVee $2005%
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BP Gas $50 (RN) ($100, $250)1.50%ITunes $15 (SN) 5%
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Buckle $25 (SN)8%ITunes $25 (SN)5%
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Buffalo Wild Wings $25 (SN, R) ($10)8%JCPenney $25 (SN, R, RN)5%
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Burger King $10 (SN, R)4%JCPenney $100 (SN, R, RN)5%
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Cabela's $25 (SN) ($100)8% Jo Ann Fabrics $256%
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Caribou Coffee $10 (SN)6%Kohls $25 (SN)4%
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Cedar Rock $253% Kohls $100 (SN)4%
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Cedar Rock $503%Lands' End $25 ($100) (SN)15%
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Cenex $253% Lewis $105%
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Cenex $1003% Lewis $205%
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Chili's $25 (SN) ($50)11% Lewis $505%
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Chipotle Mexican Grill $10 $25 (SN)10%Lewis $1005%
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Chuck E. Cheese $108%Lowe's $25 (SN, R) ($100, 500, 1,000)4%
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Cinemark Theatres $254%Maurices $207%
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Cinemark Single Ticket $9.5010%McDonalds $104%
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Claire's $109%Menards $253%
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Cold Stone Creamery $10 (SN)11% Menards $100 (500)3%
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Cracker Barrel $10 (SN) ($25)8%Michaels $254%
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Crazy 8 $25 (SN, RN)13%Nike $25 (SN)12%
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Culvers $254%Noodles & Company ($10)8%
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Dairy Queen $103%Old Chicago $256%
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Denny's $107% Olive Garden $25 (SN, R)8%
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Dick's Sporting Goods $25 ($100)8%Outback $25 ($50) 8%
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Discover $50 ($100, $250) 1.25%
Overstock.com $25 (SN)
8%
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Dressbarn $258%Panera Bread $10 (SN) 8%
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Panera Bread $25 (SN)8%
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Eagle Ave Car Wash- ANY denomination10%Payless Shoes $2013%
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PetSmart $255%
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New card? (name)________________________Pink RVCS $55%
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Reload current card (last 6 digits) #_______________Pink RVCS $105%
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Pink RVCS $205%
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Pink RVCS $1005%
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RebateQtyExt PriceRVCS Money - will write check for bills over $300 - Office Use
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Pizza Hut $10 (SN)8%
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Pizza Ranch $258%
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Qdoba $257%Business Name
Amount of Bill
Disc.Ck Amt
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Red Lobster (SN, R)8%
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Red Robin $25 (SN)8%Business Name
Amount of Bill
Disc.Ck Amt
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Ruby Tuesday's $258%
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Scheels $255% Business Name
Amount of Bill
Disc.Ck Amt
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Scheels $1005%
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Sears $25 (SN) ($100, $250)4%
LOCAL BUSINESS PARTICIPANTS (Eff. 12/29/2016)
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Sephora $25 (SN)5%2% Money (YELLOW)
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Shell $25 (R, RN) ($50)1.5%
Van Maanen's Radio Shack (Eff. 1/1/15)
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Shell $100 (R, RN)1.5%
Neal Chase Lumber (Eff. 9/8/15-will write a check for any amount)
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Shoe Carnival $255%3% Money (WHITE)
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Shopko $25 ($100)3%
Serenity Massage - Allison Bliek - 470-5547
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Shutterfly $25 (SN)9%
Sx Center Furniture Mart (Max. $3000/transaction – excludes labor, tax,
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Sinclair $251.50%
and delivery charges) (HAVE CHECK WRITTEN-ANY AMOUNT)
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Sinclair $1001.50%5% Money (PINK)
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Staples $25 (SN) ($100)5%
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Starbucks $10 (SN, R, RN)7% Beautycounter
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Starbucks $25 (SN, R, RN)7%
-Sarah Vander Pol-470-3638
Stone Soup
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SUBWAY Gift Card $10 (RN)6%Car Quest
Ta-Da Salon
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SUBWAY Gift Card $50 (RN)6%Cedar Rock GrillTangles
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Target $25 (RN / SN) 2.50%Clean & Shines - 578-9510
These 2 Hands-Lindsay Den Hartog
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Target $50 (RN / SN)2.50%
(first-time / one-time cleanings)
Ver's Pro Auto
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Target $100 (RN / SN)2.50% Countryside Gardens
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Texas Roadhouse $25 (SN)8% Cybrac
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T.J. Maxx $25 (SN) ($100)7% Economy Shop
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ULTA $254%
Exact Eye Care-no contacts
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Under Armour $25 (SN)11%
Family Eye Care - RV (451-6540)
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Vans $255%
First Impressions (Max. $3000/transaction – excludes labor, tax,
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Vans $505%
sales, gift certificates – 2/1/12)
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Vans $1005%
Glass Doctor (excludes house windows & shower doors) (Eff. 12/13)
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Vans $2005%
Greenworld, Inc (Max. $10,000/household per year-sign up at store)
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VISA Gift Card $50 ($100) ($250)1.25%
Ground Effects (Max. $3000/transaction-Have check written for any amount
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Walgreens $25 ($100)5%
Hi-Way Chevrolet-Buick Co. (parts & service only)
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Walmart/Sam's Club $25 (SN)2.50%
Hudson Locker (processing only)
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Walmart/Sam's Club $50 (SN)2.50%
J J's Valley Mart (excludes gas)
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Walmart/Sam's Club $100 (SN)2.50%Jim's Alignment - 470-4206
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Walmart/Sam's Club $250 (SN)2.50%Kel Brit's
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Wendy's $104%Kid's Corner
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White RVCS $5 *3% LaFamme Salon
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