SCRIP STANDING MONTHLY ORDER FORM
Print this form and bring to school.

Family    Name:                        ________________________________________________

E:mail or Telephone #:                        ________________________________________________

SCRIP ORDER:

Vendor Name            #- $            Vendor Total

i.e         QFC            2 - $100            $200.00

            QFC            1 - $50            $50.00

• Please refer to the order form for vendor’s names and $ denominations.

1._________________________            _______________            ________________

2._________________________            _______________            ________________

3._________________________            _______________            ________________

4._________________________            _______________            ________________

5._________________________            _______________            ________________

I would like my standing monthly order filled on the following day, each month from September – June:  ____________________ (i.e. the first Friday of each month, the 5^th, the 10^th, the 15^th, the 20^th, the 30^th)  Standing monthly orders will be available in the SCRIP sales office on the chosen date or sent home in your child’s back pack if SCRIP has a current Hold Harmless form on file.

Method of payment:            ______  Check *            ______  Credit Card **

• If using a check, please attach post dated checks to your order form, one for each monthly order, the checks will be deposited as each order is filled.  Make checks payable to St. Monica SCRIP.

• VISA or MasterCard #:_________________________________________________________

Expiration Date:  _____________   Name on Card:  __________________________________

$1.67% administration fee will apply to all credit card transactions

SIGNATURE:  _______________________________________
DATE:  ____________

STANDING MONTHLY ORDERS MAY BE CANCELLED AT ANY TIME DURING THE YEAR.