St. Joseph Scrip Program

Retailer Enrollment Form

Company Name: ___________________________________________

Address: __________________________________________________

Phone:_______________Fax:________________E-mail:____________

Contact Name:  ____________________________________________

Dollar denominations offered: _________________

Discount percentage offered:   _________________

Company usage guidelines: _________________________________________________________

__________________________________________________________________________________________________________________

How would you like the order communicated to your company on Monday mornings? (choose one)

Phone: ______________ Fax:______________ Email:_____________

What day can St. Joseph pick-up the scrip money? (choose one)

Tuesday                                  Wednesday                   

Time: ___________                Time: __________       

Pick up location _______________________________________________

Or,

Will be shipped by retailer via _________________________________

                                                                           (Carrier)

to Parish Center Office.

Thank you for participating in the St. Joseph Scrip Program!

Please Fax this completed form to 419-882-5235