*Payment Option: *Delivery Option: Please Check if you are a first time Buyer
If paying by check, and you want your order sent home in brown envelope, please drop off your check in a Scrip drop box.
Drop boxes are located in the school entrance and at the child care entrance. Otherwise, bring your check to the next Scrip sale.
Credit for: If Credit is for other family, please list:
Email: (Please enter your email address so we can respond to your order or comments)
Fill in "Qty" with the quantity you need, where Amt. is listed as any, fill in total amount to the nearest $5.
This form will automatically calculate your Grand Total. ( *=generally available at Sales ◊=can use to pay on account )
| Groceries/Drug Store | % | Amt | Qty | Cleaners | % | Amt | Qty | Retailers | % | Amt | Qty |
| *Carriage Cleaners | 10% | $10 | *Lowes | 4% | $25 | ||||||
| *HyVee/Drug Town | 3% | $10 | *Citywide Cleaners | 10% | $10 | 4% | $100 | ||||
| * | 3% | $25 | Duchess Cleaners | 5% | $10 | *MT Cartridges | 10% | $10 | |||
| * | 3% | $50 | Maurices/The Closet | 7% | $20 | ||||||
| * | 3% | $100 | *Menards | 3% | $25 | ||||||
| Nelson's Meat | 8% | $25 |
Retailers |
3% | $100 | ||||||
| *CVS Pharmacy | 2% | $25 | Ace Hardware | 4% | $25 | *Mr. Movies | 20% | $10 | |||
| Walgreen's | 2% | $20 | Adcraft Printing | 10% | $20 | Nevada Bob's Golf | 3% | $25 | |||
| Allied Moving & Strg | 5% | $25 | Office Max | 5% | $25 | ||||||
| prearrange pymt | $100 | *Old Navy/Gap | 9% | $25 | |||||||
| Gas Stations | American Eagle | 8% | $25 | *Payless Shoes | 13% | $20 | |||||
| *BP/Amoco Gas | 2% | $50 | AT&T 100+ Min Card | 20% | $9.50 | *Pier One Imports | 9% | $25 | |||
| *Casey's | 3% | $50 | Avon - Gina Cole | 10% | $5 | Pierson's Flowers | 10% | $10 | |||
| *Hawkeye Sinclair | 5% | $50 | *Barnes & Noble | 9% | $10 | *PlayStation | 25% | $6.05 | |||
| Texaco | 2% | $25 | *Bath & Body Works | 13% | $10 | Potter's Obsession | 10% | $5 | |||
| *Bed Bath & Beyond | 7% | $25 | 10% | $10 | |||||||
| Restaurants | Best Buy | 2% | $25 | Pottery Barn | 8% | $25 | |||||
| A & W | 5% | $5 | 2% |