Created: 11/28/2012 11:05:18 PM

Family Order Form

Balboa Middle School Gift Card Order Form

Orders sent on the 2st Tuesday of each month. Please sign below if you would like your child to pick up cards on delivery dates. Your
signature authorizes the release of gift cards and will not be be held responsible if lost or stolen.
Name

Customer #

Check #

Order Date

Product

Total

Product

Total

Product

76 Gas $100.00

1.50%

Body Shop $25.00

8.00%

Dick's Sporting Goods

$25.00

8.00%

76 Gas $25.00

1.50%

Buca di Beppo $25.00

8.00%

Disney $100.00

2.00%

Ace Hardware $100.00

4.00%

Buffalo Wild Wings

$10.00

8.00%

Disney $25.00

2.00%

Ace Hardware $25.00

4.00%

Domino's Pizza $10.00

8.00%

7.00%

Buffalo Wild Wings

$25.00

8.00%

Aeropostale $25.00

4.00%

8.00%

8.00%

Albertsons $100.00

Build-A-Bear Workshop
$25.00

Dream Dinners $75.00

Dressbarn $25.00

8.00%

Albertsons $25.00

4.00%

Burger King $10.00

4.00%

EB Games $25.00

3.00%

Amazon.com $100.00

4.00%

Burlington Coat Factory

$25.00

8.00%

4.00%

Cabela's $25.00

11.00%

Edwards Theatres
$25.00

8.00%

Amazon.com $25.00

10.00%

15.00%

California Pizza Kitchen

$10.00

4.00%

9.00%

Carl's Jr. $10.00

5.00%

American Eagle
Outfitters $25.00
American Girl $25.00

% QTY

% QTY

Edwards Theatres
Premiere Ticket $9.50

% QTY

El Pollo Loco $10.00

6.00%

$
$

Arby's $10.00

8.00%

Casual Male XL $25.00

9.00%

**12.00
%

ARCO $100.00

1.50%

Catherines $25.00

6.00%

Express for Men $25.00 **12.00

%

ARCO $50.00

1.50%

Exxon $50.00

1.50%

8.00%

Cheesecake Factory
$25.00

5.00%

AutoZone $25.00

Chevron $100.00

1.50%

1.50%

Family Christian Stores

$25.00

9.00%

Babies-R-Us $20.00

Chevron $50.00

1.50%

Foot Locker $25.00

9.00%

Baja Fresh $25.00

7.00%

$
Children's Place $25.00 12.00%

GameStop $25.00

3.00%

Banana Republic
$25.00

14.00%

$
Gap $25.00

14.00%

9.00%

Chili's Grill & Bar

$25.00

Barnes & Noble

Booksellers $10.00

GNC $25.00

8.00%

Barnes & Noble

Booksellers $100.00

9.00%

Golfsmith $25.00

8.00%

Barnes & Noble

Booksellers $25.00

9.00%

Barnes & Noble

Booksellers $5.00

9.00%

Barnes & Noble College

Bookstores $100.00

9.00%

Bass Pro Shops $25.00

$
$
$

Chipotle Mexican Grill

$10.00

11.00%

Express $25.00

Total

10.00%

Cinemark Theatres
$25.00

4.00%

Great Clips $25.00

8.00%

Cinemark Theatres
Single Admit $9.50

15.00%

Groupon.com $25.00

7.00%

4.00%

4.00%

Circle K $25.00

1.50%

Guitar Center $25.00

Claim Jumper $25.00

9.00%

Hallmark $25.00

**12.00
%

Claire's $10.00

9.00%

Harry & David $25.00

10.00%

8.00%

4.00%

**13.00
%

Coco's Restaurant &

Bakery $10.00

Home Depot $100.00

Bath & Body Works

$10.00

Home Depot $25.00

4.00%

Bath & Body Works

$25.00

**13.00
%

Coffee Bean & Tea Leaf

$25.00

9.00%

$
HomeGoods $100.00

7.00%

Bed Bath & Beyond

$100.00

7.00%

Cold Stone Creamery

$10.00

8.00%

HomeGoods $25.00

7.00%

**7.00
%

Honey Baked Ham

$25.00

7.00%

CVS/pharmacy $100.00

12.00%

Bed Bath & Beyond

$25.00

**7.00
%

8.00%

3.00%

CVS/pharmacy $25.00

IHOP $25.00

Best Buy $100.00

4.00%

8.00%

3.00%

Del Taco $10.00

Islands $25.00

Best Buy $25.00

iTunes $15.00

5.00%

iTunes $25.00

5.00%

Big 5 Sporting Goods

$25.00

8.00%

Make Checks Payable To:

BMS PTA

Dick's Sporting Goods

$100.00

8.00%

Total Due All Columns:

**Limited time bonus offer. Participating retailers and products are subject to change without notice.

Created: 11/28/2012 11:05:18 PM

Family Order Form

Balboa Middle School Gift Card Order Form

Orders sent on the 2st Tuesday of each month. Please sign below if you would like your child to pick up cards on delivery dates. Your
signature authorizes the release of gift cards and will not be be held responsible if lost or stolen.
Name

Customer #

Check #

Order Date

Product

Total

Product

J. Crew $25.00

13.00%

Office Max $25.00

J. Jill $25.00

**11.00
%

Old Navy $25.00

Jack in the Box $10.00

% QTY

4.00%

Total

Product

5.00%

% QTY

Sears $25.00

14.00%

Olive Garden $25.00

9.00%

8.00%

% QTY

Total

**6.00
%

See's Candies $16.90

20.00%

See's Candies $25.00

9.00%

Jamba Juice $10.00

7.00%

Outback Steakhouse
$25.00

Sephora $20.00

4.00%

jcpenney $100.00

5.00%

Overstock.com $25.00

8.00%

Shell $100.00

2.50%

jcpenney $25.00

5.00%

P.F. Chang's China

Bistro $25.00

8.00%

Shell $25.00

2.50%

Jo-Ann Fabric and Craft

Stores $25.00

6.00%

Panera Bread $10.00

**11.00
%

Shell $50.00

2.50%

**13.00
%

**11.00
%

Six Flags One-Day

Admission Ticket
$37.75

8.00%

Panera Bread $25.00

KFC $5.00

8.00%

8.00%

Smart & Final $100.00

5.00%

Kmart $25.00

**6.00
%

13.00%

Smart & Final $25.00

**5.00
%

Kmart $50.00

**6.00
%

Peet's Coffee & Tea

$20.00

8.00%

Smart & Final $50.00

**5.00
%

Kohl's $100.00

4.00%

Pep Boys $20.00

4.00%

Souplantation $25.00

8.00%

Kohl's $25.00

4.00%

PetSmart $25.00

Sports Authority $25.00

8.00%

9.00%

**6.00
%

Limited $25.00

9.00%

Sprouts Farmers
Market $100.00

8.00%

Pier 1 Imports $25.00

5.00%

Little Caesar's Pizza

$20.00

Sprouts Farmers
Market $25.00

5.00%

4.00%

Pizza Hut (Not AK or

HI) $10.00

8.00%

Lowe's $100.00

8.00%

Sprouts Farmers
Market $50.00

4.00%

Pottery Barn $100.00

5.00%

Lowe's $20.00
Lowe's $25.00

4.00%

Pottery Barn $25.00

8.00%

Staples $100.00

**10.00
%

10.00%

Staples $25.00
4.00%

**10.00
%

RadioShack $25.00
Rainforest Cafe $25.00

9.00%

Starbucks $10.00

**10.00
%

Red Lobster $25.00

9.00%

Starbucks $25.00

**11.00
%

**10.00
%

Starbucks $5.00

8.00%

**10.00
%

Subway $10.00

3.00%

15.00%

Subway $50.00

3.00%

12.00%

Regis Salons $25.00

8.00%

Supercuts $25.00

8.00%

Rite Aid $25.00

4.00%

T.J. Maxx $25.00

7.00%

8.00%

Taco Bell $10.00

5.00%

Journeys $25.00

Papa John's Pizza

$10.00
Payless Shoes $20.00

Quiznos $10.00

Macaroni Grill $25.00

11.00%

Macy's $100.00

10.00%

Macy's $25.00

10.00%

Marshalls $100.00

7.00%

Marshalls $25.00

7.00%

Men's Wearhouse
$25.00

8.00%

Regal Entertainment
Group $25.00

Michaels $25.00

4.00%

Mimis Cafe $25.00

8.00%

Regal Entertainment
Group Premiere Ticket
$9.50

Mobil $50.00

1.50%

Nike $25.00

12.00%

Red Robin $25.00

Sunglass Hut $25.00

10.00%

Ross Dress for Less

$25.00

NOOK by Barnes &

Noble $100.00

9.00%

Sam's Club $100.00

2.50%

Target $10.00

2.00%

Office Depot $100.00

4.00%

Sam's Club $25.00

2.50%

Target $100.00

2.00%

Office Depot $25.00

4.00%

Sears $100.00

**6.00
%

Target $25.00

2.00%

TGI Friday's $25.00

9.00%

Noah's Bagels $10.00

Office Max $100.00

5.00%

Make Checks Payable To:

BMS PTA

Total Due All Columns:

**Limited time bonus offer. Participating retailers and products are subject to change without notice.

Created: 11/28/2012 11:05:18 PM

Family Order Form

Balboa Middle School Gift Card Order Form

Orders sent on the 2st Tuesday of each month. Please sign below if you would like your child to pick up cards on delivery dates. Your
signature authorizes the release of gift cards and will not be be held responsible if lost or stolen.
Name

Customer #

Check #

Order Date

Product

% QTY

Total

Toys-R-Us $20.00

1.50%

ULTA $25.00

4.00%

United Artist Theatres

$25.00

8.00%

United Artist Theatres

Single Admit Premiere
Ticke $9.50

15.00%

Vons $100.00

4.00%

Vons $25.00

4.00%

Walgreens $25.00

6.00%

Walmart $100.00

2.50%

Walmart $25.00

2.50%

Wendy's $10.00

4.00%

Wet Seal $25.00

**7.00
%

Whole Foods Market

$25.00

3.00%

Williams-Sonoma
$25.00

8.00%

Make Checks Payable To:

BMS PTA

Total Due All Columns:

**Limited time bonus offer. Participating retailers and products are subject to change without notice.