TJMC Grocery Scrip Order Form (updated 3/15/08)

PLEASE PRINT CLEARLY OR USE LABEL

Name: ___________________________________

Address:__________________________________

City/ST/Zip:_______________________________

Phone # or e-mail: ______________________

Date: _______________________

     INDICATE METHOD TO RECEIVE SCRIP:

    Mail to you?  Y   N

    Pick up at Church office?  Y   N

    Pick up next Sunday at Scrip Table?  Y   N

#Gift Cards

Giant
$50 # _________ = $__________
$100 # ________ = $__________
$200 # ________ = $__________
Food Lion
$50 # __________ = $__________
$100 # _________ = $__________
$200 # _________ = $__________

Harris Teeter
$50 # _________ = $__________
$100 # ________ = $__________
Kroger
$50* # _________ = $__________

*refillable GiftCard
Integral Yoga
$20 # _________ = $__________
$50 # _________ = $__________

Rebecca's
$25 # _________ = $__________
Whole Foods
$50 # _________ = $__________
$100 # ________ = $__________
 

Total Purchase Amount: $__________________

Please make check payable to TJMC- Scrip

-To get your Scrip right away, take order form and check to the Scrip table on Sundays.
-To pre-order, place order form and check in the Scrip church mailbox (#1), or mail them to:
Trudy Rohm, 1774 Old Brook Rd, Charlottesville, VA 22901