SPECIAL ORDER FORM
Saint Dorothy –Dot’s Dollars ProgramDate: ______
Name: ______Phone #: ______
Address: ______
Please make check payable to Saint Dorothy H & S
Stores / Denomination / # of cards / $ AmountAce Hardware / $25
$100 / 4%
Aeropostole / $25 / 7%
Amazon.com / $25
$100 / 4%
American Eagle Outfitters / $25 / 10%
Barnes & Noble Bookstores / $25
$100 / 9%
Bath & Body Works / $25 / 13%
Bed, Bath & Beyond / $25 / 7%
Best Buy / $25
$100
$250 / 3%
Blockbuster Gift Card / $10 / 7%
Boscov's / $25 / 8%
Build-a-Bear Workshop / $25 / 8%
Champs Sports / $25 / 9%
CVS / $100 / 6%
Dell Computer / $100 / 4%
Disney Store / $25
$100
$1000 / 2%
Dress Barn / $25 / 8%
Eddie Bauer / $25 / 10%
FinishLine / $25 / 10%
Footlocker Stores / $25 / 9%
Genuardis / $25
$100 / 4%
Giant Foods / $100 / 4%
GNC / $25 / 8%
Gymboree / $25 / 13%
Hallmark / $25 / 4%
Home Depot / $100
500 / 4%
Home Shopping Network / $25 / 6%
iTunes / $15 / 4%
J Crew / $25 / 13%
Jiffy Lube / $30 / 8%
Jo-Ann Fabrics / $20 / 6%
K Mart / $25
50 / 4%
L.L. Bean / $25
100 / 15%
Land's End / $25
100 / 16%
Lord & Taylor / $25 / 8%
Lowes Home Improvement / $100
500
1000 / 4%
Macy's / $25
100 / 10%
Mens Warehouse / $25 / 8%
Michael's / $25 / 4%
Nike / $25 / 12%
Office Depot / $25 / 4%
Office Max / $25 / 5%
Payless / $20 / 13%
Pep Boys / $20 / 4%
Pet Smart / $25 / 4%
Pier 1 Imports / $25 / 9%
Pottery Barn/ Williams-Sonoma / $25
100 / 8%
Radio Shack / $25 / 4%
Sam's Club / $25
100
250 / 2%
Sears / $25
100
250 / 4%
Shutterfly / $25 / 9%
Sports Authority / $25
100 / 8%
Staples / $100 / 5%
Sunglass Hut / $25 / 12%
Target / $100 / 2%
Talbots / $25 / 11%
Tanger Outlets / $25 / 8%
TJ Maxx/ Home Goods/ Marshalls / $25
$100 / 7%
Toys/Kids/Babies-R-Us / $20 / 1.5%
Wal-Mart / $25
100
250 / 2%
Walgreens / $25
100 / 6%
Restaurants / Amount / Discount
Applebee's / $25
50 / 8%
Arby's / $10 / 8%
Baskin Robbins / $2 / 9%
Bob Evans / $10 / 10%
Boston Market / $10 / 12%
Burger King / $10 / 4%
Carrabba's Italian Grill / $25 / 5%
Casey's (Drexel Hill, PA) / $25 / 10%
Cheesecake Factory / $25 / 5%
Chili's/ Maggiano's / $25 / 9%
Chuck E. Cheese / $10 / 8%
Cold Stone Creamery / $10 / 8%
Cracker Barrel / $10 / 9%
Crossroads / $10 / 5%
Dave & Busters / $25 / 13%
Denny's / $10 / 7%
Domino's Pizza / $5 / 5%
Hard Rock Café / $25 / 10%
Hickory Farms / $10 / 15%
Honey Baked Ham / $10 / 12%
Kentucky Fried Chicken (KFC) / $5 / 9%
Maggie O'Neill’s / $25 / 10%
Old Country Buffet / $25 / 5%
Omaha Steaks / $25 / 11%
Outback Steakhouse / $25 / 5%
P. F. Changs/Pei Wei Asian Diner / $25 / 7%
Panera Bread / $25 / 9%
Papa John's / $10 / 8%
Pizza Hut / $10 / 8%
Quotations (Media, PA) / $25 / 10%
Red Lobster/ Olive Garden / $25 / 9%
Ruby Tuesday's / $25 / 8%
Spaghetti Warehouse / $20 / 18%
Starbucks / $25 / 7%
TGI Friday's / $25 / 9%
Wendy's / $10 / 4%
Other Services
Amc - Single Ticket / $9.50 / 16%
Regal/ United Artist / $25 / 8%
Regal/United Artist - Single Ticket / $9.50 / 16%
Gift Card Wrappers / $6 / 20%
BP/ Amoco / $50 / 2%
Exxon/ Mobile / $50 / 1.50%
Shell Gas / $25
50
100 / 2.50%
Sunoc/ A-Plus / $50 / 1.50%
Texaco / $25 / 2%
TOTAL ORDER
Cash ______Check # ______